The Coach House

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 requires improvement. At this assessment the rating has changed to 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. Staff listened to concerns about safety. Safety events were investigated and reported effectively. Staff were encouraged to be open and honest and raise any concerns during discussions at staff meetings. One member of staff said, “We discuss any health and safety issues during meetings, any important concerns are discussed when they happen rather than waiting for a meeting.” The provider has taken steps to learn from their previous inspection to implement positive changes at the service. The registered manager now in post had taken steps to ensure safety is prioritised at the service. Where lessons had been learnt, these were shared with staff and steps were taken to embed good practice.

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. Before people came to the service the registered manager completed a full assessment to ensure their needs could be met. Information would be shared with staff to ensure there was continuity of care and any equipment needed was in place before people were admitted. A relative told us, “We discussed all the care needs and how best to manage these.” The registered manager told us people were registered with the local GP and any referrals needed were made. People’s continued healthcare needs were monitored. Prompt referrals were made when needed to tissue viability nurses, physiotherapist, speech and language therapist (SALT) and other health professionals when indicated.

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 registered manager understood their responsibility to keep people safe, raised safeguarding concerns promptly and took action to mitigate risks and keep people safe. Where the local authority safeguarding team were involved in investigating safeguarding concerns the registered manager worked openly with them. Staff had received training in how to safeguard people, and the provider had processes in place for staff to follow on ‘Whistle blowing’. One member of staff said, “I completed my training a few weeks ago, I would raise any concerns with the manager or report to local council depending on the issue.” The registered manager told us safeguarding was discussed during staff meetings and supervision to ensure staff were aware of how to respond to any concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the registered manager understood their responsibility to make DoLS application when required and did this in conjunction with people’s relatives and advocates. Staff had received training in the Mental Capacity Act and supported people in making informed decisions. Where possible staff gave people choice and obtained their consent for care and treatment.

The provider 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. Staff identified risks to people and put safeguards in place to mitigate these risks. Where people needed support with complex medical conditions staff had all the information they needed, to support people safely. Equipment was monitored to ensure this was being used safely to support people. The registered manager worked with people and their relatives to discuss risks and how these could be mitigated. Where people were at risk of pressure ulcers staff put measures in place to reduce this risk. Staff monitored people’s physical needs closely to reduce risks and involved other healthcare professionals when needed such as speech and language therapists and physiotherapists. People were supported to live full lives including accessing the community safely with staff.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider has taken action to ensure the environment is safe for people and staff. Where needed improvements have been made to the fire system with magnetic locks added to fire doors which were connected to the fire system to ensure safe release in the event of a fire. People had personal evacuation plans (PEEPS) in place to guide staff on how to safely evacuate them from the building. Staff had received training in evacuation procedures, and the registered manager had a system in place for staff to practice fire drills.

Window restrictors have been repaired or replaced where needed. The registered manager informed us the provider had a plan of works in place for general redecoration of the service and some of this work had commenced. The registered manager informed us they were meeting with the provider to discuss how on-going maintenance would be provided at the service, and the possibility of contracting to a local firm who could be more responsive to their needs.

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. The registered manager had taken action to ensure staff working at the service had the skills and qualification they needed to support people safely. Staff training was monitored and when this needed to be updated dates were booked in for this to be completed. Before agency staff worked at the service the deputy manager checked with the agency they had up to date training and recruitment checks in place.

The provider had employed a clinical lead to work with nursing staff to provide support and supervision to ensure that nursing staff had the support they needed to provide safe care to people.

Staff were recruited safely to work at the service this included obtaining references and Disclosure and Barring (DBS) checks. DBS provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

New staff had a full induction to the service including working shadow shifts with more experienced staff. Training was provided both on-line and face to face, staff new to care were supported with completing the Care Certificate, a national recognised set of care standards to provide staff with the skills and knowledge they need to work in the care industry. A member of staff said, “When I started, I came in and met all the residents was introduced to staff and shown all the important things. I then worked with other staff and shadowed them while I got to know people.”

Staff were supported with regular supervision and staff meetings to discuss people’s care, training needs or raise any concerns. Relatives and people, we spoke with were happy with the care and support they received. One relative said, “It is 5-star treatment.” Another relative said, “My loved one feels safe and well looked after. I am confident with what staff are doing.”

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. Staff had received training in infection prevention and control (IPC) and were able to demonstrate how they safely managed the risks of infections. Staff knew how to use and dispose of personal protection equipment (PPE) appropriately. IPC audits were completed by the registered manager to ensure IPC was being implemented correctly to prevent the risk of the spread of infections. The registered manager had identified some areas in the environment they wished to improve as part of their on-going action plan.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, on checking medication stocks we found these did not always match with people’s medication administration records (MAR). Although we found no impact on inspection, medication audits were only completed monthly, this meant there was a risk of issues not being identified and addressed promptly. The registered manager said they would address this by returning to a weekly audit of medicines.

The registered manager informed us they had an electronic medication system in use which staff were now more familiar with, and this was working well for them.

Staff responsible for administering medicines had their competency checked to ensure they had the skills to do this safely.