Stockingate Residential 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 for example, the way people’s medicines were managed, IPC measures and the monitoring of people’s safety. We have requested an action plan from the service as to how they plan to make improvements to ensure safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had systems and processes in place to facilitate a positive learning culture. There was an accidents and incidents tracker in place that analysed information for emerging themes and trends. Any areas of learning were discussed with staff in team meetings or during supervision. Staff told us there was a positive learning culture within the service whereby any incidents, accidents or safeguarding concerns are discussed in a positive way with them by leaders of the service. One staff member told us any accidents and incidents are, “Discussed with the wider team and the right people are involved.”

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service had systems and processes in place to work with people and healthcare partners to monitor and manage risk, however, these were not always utilised. Handover documentation lacked important, detailed information for staff supporting people to have a full understanding of any change in need, risk or support. Systems were in place to monitor people’s safety but were not always utilised. For example, care planning audits completed by leaders did not always identify contradictory information regarding people’s skin integrity or dietary needs. Healthcare partners told us the service did not always maintain safe systems of care when working with them. One professional told us, “They [staff and leaders] are not always very good at risk assessing people’s health needs.” The service advised us how they plan to make changes to ensure safe systems and processes, having already implemented some changes.

The service 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 service shared concerns quickly and appropriately.

The service shared safeguarding concerns appropriately with external agencies. There was a safeguarding audit in place which analysed emerging safeguarding themes and trends. Staff were trained in safeguarding and demonstrated a good understanding of safeguarding policies and procedures. People and relatives, we spoke with advised they feel safe with staff supporting them in the service. One person told us, “Yes I do feel safe with staff.”

There were robust systems in place regarding best interest decision making and Deprivations of liberty safeguards (DoLS). People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application for DoLS.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service made referrals to appropriate external agencies in order to manage risk. Most professionals we spoke with advised us the service makes appropriate contact with them to escalate any concerns to manage risk. One professional told us, “If they have any concerns about the residents, they ring us straight away.” People within the service told us relevant professionals were involved in their care to manage risk. One person told us, “I see an optician, a GP comes to the home.” We did receive some negative feedback from one professional who advised the service needed to improve their risk assessments of health needs as the service over refers. The service has advised us how they plan to make changes to ensure good working relationships with partners to manage risk.

The service 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 appropriate fire safety procedures in place, and the service completed regular maintenance checks for environmental risk such as legionella testing. However, areas of the service were unsafe for people to access. For example, the garden area had several sharp objects and trip hazards, posing a risk to people and staff safety for those using the area. The service’s medication room also stored inappropriate items such as alcohol and cigarettes. The service rectified this immediately and have advised us on how they will make improvements for a safe environment.

The service did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service had robust recruitment processes in place. Staff were provided with regular supervision and appraisals. However, we were not provided with evidence all staff had received appropriate training to fulfil their role. The staff dependency tool identified the staffing level to be over the required number, and we observed good staff deployment throughout the service. However, we received mixed feedback from people about the staffing levels within the service. When asked, 1 relative told us, “Not enough staff,” whereas another relative told us, “There seems to be a lot of staff, always somebody in the lounge sat with them [people].” Staff also provided mixed feedback on staffing levels. One staff member told us, “Personally. I think there is enough staff.” Another member of staff told us, “There are sometimes less staff due to sickness.” The service has advised us as to how they make improvements to ensure safe staffing, having already implemented changes.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed there to be poor IPC measures within the service. There was an IPC policy in place, however, this did not detail IPC measures such as cleaning schedules required. Documentation identified bedrooms were cleaned regularly, however, some communal areas were not always cleaned daily as required. We observed several areas such as the medicines room, food storage and main lounge area, were not sufficiently cleaned to prevent the spread of infection. We received mixed feedback from people and relatives using the service regarding infection prevention. One relative told us, “I’ve not seen them do much cleaning at all.” However, 1 person told us, “The home is cleaned every day.” Leaders rectified main areas of concern immediately and have provided an action plan to improve IPC measures more widely throughout the service.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not involve people in planning.

We observed there to be poor medicines management within the service, placing people that at risk of harm. There were processes in place to ensure the safe management of medicines, however, these were not utilised, for example, medication audits. These did not have dates as to when these were completed or who had completed them. Some people using the service were given their medications covertly or as and when required. There was a lack of appropriate documentation or support in place to support processes relating to these medicines, for example, a lack of direction from a local pharmacist or best interest documentation. The service did not always document when medicines were given to people, this posed a significant risk in relation to those with time sensitive medications. People or their relatives did not express concerns in relations to the management of medicines. One relative told us, “The home has been brilliant with medication.” The service has advised us on how the plan to improve medicines management, having already implemented changes.