Cambron 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were recorded and analysed to identify trends and patterns to mitigate future risks. We saw the registered manager was continually looking at ways to learn from events and sought guidance. For example, following a recent local authority review they had considerably improved safeguarding outcomes and actions. These were disseminated to all staff to ensure improved practices. The registered manager also took on board our initial inspection feedback and immediately improved care plan documentation to ensure people's safety.

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. Important information was shared with healthcare professionals when appropriate to ensure people received consistent care and support.

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 shared concerns quickly and appropriately. The provider had a process in place to ensure safeguarding concerns were acted upon and people’s safety maintained. The registered manager kept an organised record which clearly detailed outcomes and any actions to required.

The principles of the Mental Capacity Act 2005 (MCA) were understood by the registered manager and there were processes in place to review people’s capacity in line with the MCA.The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. 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 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA. People had care plans in place to ensure DoLS were recorded and people supported in line with them. Where people lacked capacity, best interest decisions had been completed to ensure their views, wishes and preferences were considered.

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. Risks associated with people’s care were not always identified and managed to keep people safe. For example, manual handling plans did not always include clear instructions for transferring people using a hoist. For example, the sling size and loop configurations were not always documented. Fluid intake and the risk of weight loss was not always recorded effectively. We raised these concerns with the registered manager who took swift actions to keep people safe. The registered manager reviewed care plans, so they reflected people’s needs better.

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. We found some environmental risks which had not previously been identified. Some tall furniture was not securely fixed to the wall, and 2 small windows did not have window restrictors in place. The registered manager addressed these issues immediately 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. The provider had a recruitment process in place which supported them to recruit staff who were suitable to work with vulnerable people. Staff received training and support to carry out their roles effectively. There were sufficient staff available to support people in line with their needs.

The provider 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 carried out a tour of the home with the registered manager and identified some areas which required cleaning more effectively. For example, shower chairs required cleaning and storerooms required tidying to ensure they could be cleaned effectively. We raised these issues with the registered manager who took swift actions to address our concerns.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed by staff who were trained and competent in the safe administration of medicines. However, we found some minor issues with medicine records which were thoroughly investigated following our inspection. People who required medicines on an ‘as and when’ required basis, had protocols in place to ensure they were administered safely.