Boulters Lock 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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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, positive safety culture, grounded in 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.

For example, during an outing, an incident involving a wheelchair occurred. Although no harm had come to the person, the registered manager had taken appropriate action to improve and strengthen their safety checks of all equipment to help reduce risk for people. They told us, “We need wheelchairs that are specifically for outdoors. We are hoping to source this soon. We ensured lessons were learned with all staff. We also ensure all equipment is checked and risk assessment reviewed and updated.”

The managers held regular quality assurance monitoring meetings to share good practice, identify trends, and analyse where improvements were needed. The registered manager told us, “We always learn from incidents and accidents. Our compliance team investigates the cause and shares it with families. We have a central analysis of all incidents.”

People told us they were happy living at the service and felt safe and well cared for. One person stated, “I do feel safe living here… there is always someone around.” Incidents and accidents, safeguarding concerns and complaints were recorded on the provider’s system. These were reviewed, discussed and analysed to determine any underlying causes or trends and to identify any actions required to improve the service.

The registered manager understood their responsibilities under the Duty of Candour and were able to demonstrate this. They explained that they always wrote to relatives if a family member had an accident or if anything was of concern. We saw letters on file, sending apologies as needed.

The provider worked with people, relatives and healthcare professionals to maintain safe and effective systems of care. Staff ensured information was shared appropriately so there was continuity of care when people moved between different services. Healthcare professionals told us they had a positive working relationship with the service and described communication as timely and consistent. People received regular input from external professionals, including GPs and district nurses, which helped ensure their health needs were monitored and met. People told us they felt safe at the service. They told us the staff were available if they needed support. Relatives stated they were informed when their family members required support or treatment from different agencies.

Transitions into the service could be unsettling for people and carried a risk of confusion or distress. The registered manager explained the measures taken to reduce this risk. They said, “We encourage relatives to be here when the person arrives, and to get their rooms prepared with objects of their choice. We invite people to visit the home first, so they feel more familiar when they move. Staff liaise with family members to make the transition easier.” This helped people settle more comfortably and supported a smoother move into the service.

There was also a risk that important information could be missed when people attended hospital or moved to another care setting. The regional manager told us, “We have hospital packs so the information about the person goes with them, if they go to hospital or move to another service.” Records confirmed these packs were used consistently. This supported accurate information‑sharing and reduced the likelihood of delays or inappropriate care.

People told us they felt safe living at the service and were confident staff would support them when needed. One person told us, “I do feel safe living here… there is always someone around.” Relatives also said they were informed when their family member required support or treatment from other agencies, which reassured them that communication was effective.

Overall, systems to manage risk and coordinate care were reliable and worked well in practice. Staff responded appropriately when people’s needs changed, and there was effective communication with external partners. While improvements were largely in line with expected good practice rather than innovative or exceptional, these systems contributed to safe, consistent and well‑coordinated care.

The provider worked with people and healthcare partners to understand what being safe meant to them and how best to support this. Staff focused on improving people’s lives while protecting their rights to live free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared any concerns promptly with the appropriate agencies.

People told us they felt safe from harm and abuse. One person said, “I am happy and safe here.” Relatives agreed, commenting, “My relative is happy and that is all that matters,” and “I don’t have any worries. The staff are well trained here.”

Staff had received safeguarding training and regular refresher sessions to keep their knowledge up to date. Staff were able to clearly describe signs of potential abuse and the actions they would take. Records confirmed the provider was proactive in raising safeguarding concerns with the local authority and CQC and worked with relevant professionals to investigate incidents when they occurred. The registered manager told us, “We did have a whistleblowing last year. We reinforced with staff about reporting, and they have the contact details should they need to raise concerns.”

The provider understood their responsibilities under the Mental Capacity Act 2005, including ensuring Deprivation of Liberty Safeguards (DoLS) applications were made appropriately.

The provider worked with people to understand and manage risks in a holistic way. Staff delivered care that was safe, supportive and helped people continue doing the things that mattered to them.

People told us staff knew their needs well and supported them safely. One relative said, “I’m fairly certain that since being here my [family member] hasn’t had a fall – I’m here a lot and I’m sure they would have told me.”

There were effective systems to identify, assess and reduce risks to people. Risk assessments were detailed, regularly reviewed and included severity scoring to guide staff. For example, some people were at risk of developing pressure ulcers or at risk of falls. Appropriate measures were in place, including pressure‑relieving equipment and ongoing review of needs with healthcare professionals, such as the tissue viability nurse. This helped reduce the likelihood of avoidable harm.

Care plans contained clear information about people’s medical conditions, early signs of deterioration and the actions staff should take. For people living with conditions such as diabetes, epilepsy or Parkinson’s, care plans described symptoms to monitor and when to escalate concerns. This supported staff to recognise changes promptly and seek appropriate healthcare input.

Incidents and accidents were recorded and contained details such as a description of events leading up to the incident, action and response and post incident analysis. Each report also highlighted what had been put in place to prevent re-occurrence. Following the incident, an action plan was put in place and care plans and risk assessments were reviewed.

The provider identified and controlled potential risks within the care environment. Equipment, facilities and technology were maintained to support the delivery of safe care.

People lived in a safe and well‑maintained environment that met their needs. There were effective systems to monitor the condition of the premises and identify issues such as faulty equipment or trip hazards. Daily and weekly safety checks were completed, including water temperatures, fire safety checks and monitoring of kitchen equipment. Staff told us repairs were acted on promptly when concerns were raised.

Equipment used to support people was suitable for their needs, regularly serviced and stored securely. The provider also had an up‑to‑date emergency plan to guide staff in the event of an unexpected incident.

Personal emergency evacuation plans (PEEPs) were in place for each person and included clear information about the assistance they required to evacuate safely during a fire or emergency. This helped ensure people could be supported quickly and appropriately should an incident occur.

The provider ensured there were enough qualified, skilled and experienced staff to meet people’s needs safely. Staff worked well together and received appropriate support, supervision and training to provide safe and consistent care.

People were not always able to tell us whether staffing levels met their needs, but relatives told us they had no concerns. One relative said, “It’s difficult to tell if there are enough staff – you can always find someone if needed and I don’t sense that they are rushed.” This helped reassure us that the staffing arrangements in place were effective.

There were safe recruitment processes to reduce the risk of unsuitable staff being employed. Checks included verification of identity, right to work in the UK and Disclosure and Barring Service (DBS) checks. These checks help employers make safer recruitment decisions by identifying criminal convictions or cautions.

Staff told us they were happy working at the home, felt supported and had access to the training they needed. A learning and development manager coordinated training to ensure staff remained up to date. The registered manager said, “The local authority provides training such as falls, infection control, diabetes and safeguarding. Next Monday, it’s about providing activities training and dementia.”

New staff completed an induction covering health and safety, mandatory training and time to get to know people living at the home. They were also introduced to training specific to people’s needs, such as dysphagia, dementia and diabetes. New staff undertook a period of shadowing experienced colleagues, and their competency was assessed before working independently.

The provider assessed and managed infection risk. They detected and managed the risk of its spread and promptly shared their concerns with appropriate agencies.

People told us they felt safe from the risk of infection because premises and equipment were kept clean and hygienic, and relatives confirmed they did not have any issues with the cleanliness of the service. People and relatives commented, “It is nice and clean. There are no problems there”, “It’s very clean. I’m glad to say that the toilets are kept clean”, and “It’s always nice and clean – the bed linen looks fresh.”

Appropriate systems were in place for infection control. The provider ensured staff had access to protective personal equipment and were trained in the use of this. Care staff wore this appropriately when supporting people to help protect them from cross-infection.

The provider’s infection prevention and control policy was up to date. Information about the risk of infection was shared appropriately with people and visitors. The managers and senior staff carried out audits to ensure high standards of cleanliness.

The provider ensured medicines were managed safely and in a way that met people’s needs, capacities and preferences. Some people were prescribed medicines on a ‘when required’ basis for conditions such as pain, anxiety or constipation. Protocols for these medicines were person‑centred and provided clear guidance for staff.

People told us they received their medicines as prescribed. One person said, “I do take medication and I get that on time,” and another said, “All medication is done on time. When I wasn’t well, they got antibiotics for me straight away.” A relative commented, “I’m always informed about any change of medication.” Medicines, including controlled drugs and over‑the‑counter items, were stored securely at appropriate temperatures.

Our observations and checks of medicines records showed people received their medicines safely and consistently. Staff wore ‘do not disturb’ red tabards when administering medicines to minimise distractions. We saw staff explain medicines to people, seek consent and approach people respectfully. Staff scanned each medicine, and the system displayed key information including the person’s details, type of medicine, dosage and timing. If a medicine was missed, the system generated an alert so this could be addressed promptly.

The provider used an innovative electronic medicines system recognised to increase people’s safety, improve efficiency and accountability. The registered manager had been involved in the piloting of the system and was able to feedback where improvements were needed. They told us, “It was great to have been recognised by these wider organisations and a privilege to be a part of this.” The registered manager also supported other homes with medicines training and sharing knowledge of the system and the organisation’s policies and procedures.

There was a medicines policy in place, and processes to report and investigate any medicines errors. Senior staff carried out regular audits to identify improvements. Staff received medicines training and had their competency assessed before administering medicines.