Archived: Summerhill 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 assessment we rated this key question Good. At this assessment the rating has changed to 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 that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment as people’s medicines were not always managed or recorded safely.

This service scored 62 (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.

Where lessons were learned from incidents in other care homes managed by the provider, these lessons were shared with Summerhill Care Home to ensure best practice.

Staff knew how to report safety incidents, and these were investigated by the management team.

Learning from incidents was shared in staff meetings and one-to-one meetings with staff. One staff member told us, “The [registered manager] goes through an agenda for team meetings, and we discuss any concerns. We talk about learning from incidents which leads to improved practice.” Another staff member told us, “I learned during training and from colleagues how to support people safely when they have fallen.”

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. For example, where one person had risks associated with a specific health condition, the provider worked with the person, health agencies and commissioners to support them with those risks.

People felt safe. One person told us, “I felt safe from the first days here. The way the staff reassured me and made me feel welcome gave me confidence in them. I don't have to think about being safe, I just am.”

One professional visiting the service told us, “I think the provider is really responsive and come to us regarding any health risks and what they need to do to manage them.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Staff had received safeguarding training and knew how to identify and report abuse. One staff member told us, “I have had my safeguarding training. If I saw abuse, I would report it straight away to a senior, nurse and manager. I am confident mangers would follow through with safeguarding concerns.”

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a deprivation of liberty safeguard (DoLS) was applied for through the relevant local authority.

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 that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments did not always include consistent information or did not always include people’s risks or guide staff how to manage them or escalate concerns. For example, where one person required specific support around their eating and drinking needs and risks, this information was not included in their care plan. This meant they were at risk of not having their needs met safely.

Where 1 person required support around their mobility and falls risks, their care plan did not include all the required information about what mobility aids, equipment and staff support was required. Another person’s care plan contained inconsistent information about their falls risks. This meant they were at risk of receiving unsafe or inconsistent support.

When the inspection team informed the provider about concerns with the information included in care plans, they sent updated care plans and risk assessments which included enough detail about people’s risks and how staff should support them and escalate concerns.

While we observed examples of safe moving and handling practice, when we told the registered manager about 1 incident where staff used the incorrect technique to support a person to stand, this was addressed straight away.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were effective systems in place to ensure the environment was kept safe.

Routine testing took place for fire alarms and evacuation procedures.

Environmental risk assessments were in place such as fire safety, gas safety and water safety. These were up-to-date and where issues were identified, these had been addressed or there was a plan in place to address them.

One staff member told us, “We have had renovations in the dining rooms and lounges. I have seen a lot of improvements overtime with the décor. The environment is safe, and the maintenance staff keep an eye on things. Fire doors are clear. We take part in fire safety drills and receive fire safety training.”

Environmental audits took place to monitor the safety of the premises and equipment.

People were able to move safely around the environment. There were grab rails and specialist equipment available to support people who needed these. People were provided with specialist beds, hoists, and other equipment. There were coded doors to help restrict access to non-communal areas to keep people safe.

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.

There were enough staff on duty to meet people's needs. The provider used a dependency tool to calculate the numbers of staff they needed. Staff felt they delivered safe care and had received the training required to undertake their roles safely. One staff member told us, “I am up to date with my training which is refreshed every year. I really like working with the team. We have good communication and are supportive to one another. We ask for help when needed and make sure residents needs are met.”

Following our feedback about how the service managed people’s medicines and health risks, the provider booked further training and clinical supervision for nursing staff to ensure they were up to date with best practice.

Team meetings, one-to-one meetings and daily handovers were in place to support staff to provide safe care to people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Legionella assessments were carried out in line with requirements.

Staff were provided with personal protective equipment (PPE) and were observed wearing and removing this appropriately. One person told us, “There are staff who clean my room. It is always nice, clean and tidy.” One staff member told us, “Infection prevention and control practice is important to us, and we discussed learning from an infection outbreak in team meetings as well as how to use PPE correctly.”

There were handwashing facilities throughout the building and also access to hand gel. There were clear instructions above every sink on how to wash hands properly.

Staff had received training to support with minimising the risk of infection and information about safe infection prevention and control practices was displayed throughout the care home. There was an up-to-date infection prevention and control policy in place.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

When people were prescribed a medicine to be given with a specified time interval between doses, the records showed the time interval between doses was observed. However, when medicines were prescribed to be given at a specified time, they were not always given at that time or within 30minutes (for one particular medicine) of the specified time, as set out in best practice guidelines. This meant the person might have experienced symptoms of the condition the medicine was prescribed to treat.

When people were prescribed medicines to be given ‘when required’ there was not always person-centred information available to support staff to know when to give the medicine. There was a risk people might not have been given the medicine when they needed it. When people were prescribed a medicine with a variable dose for example, 1 or 2 tablets, there was not always information to support staff to know which dose to give. There was a risk people might not have been given the most appropriate dose when they needed it.

When people were prescribed a topical preparation, for example, a cream, the records for the application of the cream was not always accurate. The site of application of medicated patches was not always recorded, therefore there was a risk the patches would not be rotated in line with the manufacturer’s instructions. This meant people were at risk of experiencing skin irritation.

We found there was not always a record made when people had thickening powder added to their drinks to reduce the risk of choking. Therefore, there was a risk people were not having their drinks thickened correctly, which meant they were at risk of choking. Following the assessment, the manager provided some evidence that records of drinks being thickened were being made.

We found staff were not always following medicines related policies and procedures, for example, the recording of the site of the application of medicated patches and the recording of creams, this placed people at risk of harm. Medicines audits were not always effective in identifying medicines related issues occurring in the service.

Staff completed medicines training and had their competency assessed.