Capwell Grange Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this inspection, the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety based on openness and honesty. A learning culture was promoted at the service in ways such as staff handovers and meetings. Incidents and accidents were reviewed to see where lessons could be learned. People’s care plans and risk assessments were reviewed regularly to ensure any learning from incidents were used to update them. One person said, ‘‘If you ask for something to be done differently then changes are made quickly.’’ A relative told us, ‘‘[Family member] is really safe and as soon as their needs change the staff team react immediately. They had a fall and all the equipment was put in place straight away.’’

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Staff supported people to access other services such as health appointments or attend services like hospital when they needed to. They liaised with services to arrange safe transport for people to other services. Staff shared important information about how people wanted to be supported with partners and professionals to help ensure safe transitions. One person said, ‘‘I like to take [transport] for my appointments, and the staff organise this for me.’’ A visiting health professional told us, ‘‘Staff are really responsive here. If we need anything it is organised straight away and we have no worries at all.’’

People were protected from abuse and improper treatment. Safeguarding concerns were taken seriously and investigated. The management team reported concerns to the safeguarding team where necessary and reviewed outcomes to see if lessons could be learned. Staff were trained in safeguarding and knew how to report concerns. One person said, ‘‘I feel very safe here. The staff are all brilliant and support you with everything you need.’’ A relative told us, ‘‘I am pleased with everything and have complete confidence that [family member] is safe.’’

The provider worked well with people to understand and manage risks. Staff followed care plans and risk assessments to ensure people were supported. Risk assessments and care plans were detailed for the most part. However, some would have benefitted from more detail in areas such as personal care and mobility. The registered manager assured us they would review and address these. Staff knew how to keep people safe and were very knowledgeable about the risks people faced and how best to mitigate these. We observed staff supporting people to use equipment such as hoists safely. A person told us, ‘‘I can’t walk very well anymore but the staff have helped me out and make sure I can use [equipment] safely.’’ A relative told us, ‘‘We were very impressed with how quickly measures were put in place to mitigate [risks] to [family member]. It gave us lots of reassurance and the equipment is always kept in prime working order.’’

The provider detected and managed all potential risks in the care environment. All areas of the environment such as living areas and bedrooms were safe. Staff kept equipment people used safe and in good working order and carried out checks of the building to help make sure it was safe. The management team responded immediately if there were any issues which may make the environment unsafe. Fire safety at the service was well understood by the management and staff team and detailed plans were in place to support people if there was an emergency relating to fire. One person said, ‘‘We practice what to do in a fire and the staff help me get out of the door.’’

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Some people and relatives told us they felt there were not enough staff to spend quality time with them outside of physical and personal care needs. The management team assured us they would focus their audits on this area to see if any improvements could be made. However we observed on all of our visits to the service, there were enough staff to support people with their needs such as personal care and eating and drinking. Staff told us they had time to chat and engage with people as well as support them with their essential care needs. Staff were trained in all areas relevant to their job roles and were confident and knowledgeable about this. The management team checked to make sure staff understood their training. The provider recruited potential new staff safely in line with legislation. One person said, ‘‘There are always plenty of [staff] about and I never have a problem getting hold of anyone.’’ A relative told us, ‘‘There are plenty of staff on hand both day and night.’’

The provider did not always assess or manage the risk of infection. Several areas of the service were unclean. These included communal bathrooms, en-suite toilets, windowsills, skirting boards and some bins not having lids on them. Audits and checks were in place to monitor the cleanliness of the service and the effectiveness of the IPC measures in place, however had not picked up on these issues. We fed this back to the management team on our first visit to the service. Whilst significant improvements were made immediately, we still found areas that required improvement in relation to cleanliness on our other visits to the service. A relative told us, ‘‘Cleanliness can be a bit hit and miss. I think it depends on the day.’’ The management team assured us they would increase monitoring in this area to keep improving the levels of cleanliness at the service.

Other areas of the service were clean. One person said, ‘‘[Staff] are in and out cleaning and tidying all the time.’’

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines on time and staff knew how people liked to be supported with them. Staff were trained to administer medicines and had their competency to do so checked regularly. People who were prescribed ‘as and when required’ (PRN) medicines had detailed guidelines in place so staff could administer them safely. One relative told us, ‘‘[Family member] has a very specific regime relating to their medicines and it is comforting to know how professional [staff] are and how seriously they take this.’’