Archived: Vale Court 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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed.

At this assessment the provider was found to be in breach of Regulations relating to safe care and treatment and safe staffing.

This service scored 50 (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 did have a proactive and positive culture of learning from safety events. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There were policies and procedures and processes in place to understand, learn and share learning with staff though group supervisions. Feedback from staff confirmed they were informed of safety events; information they needed to be aware of was shared at group supervisions and through the staff handover process.

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. The provider ensured information about the service was made available to people and families. Family members told us they were involved in supporting their loved one to move into the service and were involved with creating care plans and continued to be involved. Discussions with staff confirmed information was gathered with family members and the person when they moved into the service and regular reviews of care plans were in place while getting to know people.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider had staff champions in place overseeing safeguarding. The provider shared concerns quickly and appropriately. People told us they felt safe in the service, staff took the time and, “Nothing was too much trouble for the staff.” Family members told us they were made aware of any concerns or safety incidents promptly. Feedback from partners confirmed timely information sharing and action undertaken to mitigate risks.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs which was safe. One person who was using oxygen was not being supported to monitor the oxygen calibration and check their regular saturation levels. One person who was supported with their nutrition with a percutaneous endoscopic gastronomy (PEG), their rotation was not being monitored and recorded. One person who required to use a continuous positive airway pressure machine with mask (C-PAP) did not have a risk assessment in place to support use. One person required daily environmental checks and equipment checks, the recording system showed gaps in the required daily health and safety checks. Many mattress pressure settings were found to be incorrect for people. However, these risks described were rectified and actioned as soon as feedback was provided to the registered manager and nominated individual. We found care plans to be person centred and were reviewed regularly.

This was a breach of Regulation 12: Safe care and treatment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. There were several checks being completed on the establishment and equipment; however, the bed mattress and air pump regular checks needed clarity and clear ownership of responsibility. Internal environmental checks were not being completed regularly to support an internal environmental risk assessment, which was not in place. However, the staff training compliance for health and safety was good.

This was a breach of Regulation 12: Safe care and treatment.

The provider did not always make sure staff received effective support, supervision and development. Supervisions were held in the most part as group supervision, this was not always suitable as supervisions were not individualised and personalised.

The provider used staffing agencies, we found agency staff rostered without a health and safety induction to include agency profiles to show their experience, training and compliance checks. This was a breach of Regulation 18, staffing.

Feedback from people and family members were complimentary towards the staff. People stated they felt safe with staff and family members shared staff were, “Always available, busy, but always available.’’ Another family member stated staff were knowledgeable about their loved one when they asked questions and wanted updates on their care and support.

The provider did not always effectively assess or manage the risk of infection. The audits and practices in place did not effectively manage or responsively replace equipment to promote good infection control practices. Cushioned bed sides were found to be requiring replacing or a deep clean. The sluice room was being used to store equipment on the floor, we shared this feedback with the registered manager, and they removed the equipment from the sluice room straight away. The kitchenette upstairs required a deep clean to include the kitchen units and the dining room furniture. Clean laundry was found on trolleys stored in bathrooms and shower rooms. Lap tables were found to be requiring a clean or to be replaced. This was a breach of Regulation 12: Safe care and treatment. However, we observed cleaning schedules in place, deep cleaning schedules and staff training in place. There were dedicated staff undertaking weekly infection prevention and control (IPC) audits who were IPC champions. Feedback from partners was positive, the provider did access support when required and had been reporting infection outbreaks in the service appropriately. Family members were complimentary about the tidiness and cleanliness of the service when they visited.

The provider made sure medicines were safe and met people’s needs, capacities and preferences. However, we found the provider did not always make sure treatments were safe, and staff training was compliant. We found prescribed topical creams in people’s rooms were not in a locked cabinet and in the medication room were not labelled on opening. We found food and drink thickening agent in a communal kitchenette upstairs which was not securely stored. Medication audit actions were not fully completed or actions transferred from one audit to another. Staff competence assessment compliance for the use of food and drink thickening agent was showing over 50% of staff required this training. PEG competencies were low for the nursing staff. All staff involved in the use of home oxygen, must have appropriate and ongoing training in safe oxygen storage and use, this training was not showing on the training compliance data. Competency assessments required for staff who administer prescribed topical creams were showing at least 50% of staff required this competency assessment. This was a breach of Regulation 12: Safe care and treatment. However, medication administration training and the medication competencies for administration was good.