De Bruce Court

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 provider was in breach of Regulation 12 because risks to people’s safety were not always assessed, monitored or mitigated effectively.
 

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 provider had not established an effective learning culture in relation to safety. Incidents and concerns were not always investigated, analysed or used to identify learning and reduce the risk of recurrence.

Incident records showed staff recorded what had happened and any immediate action taken. However, follow-up actions were not always sufficiently detailed to show how risks would be reduced or how similar incidents would be prevented. The interim manager told us lessons learned were not always recorded or analysed. This meant opportunities to improve the safety and quality of care were missed.
 

The provider had safe systems, pathways and transitions in place to identify, monitor and respond to risks, helping to reduce the likelihood of harm and promote people's safety.

Staff recognised changes promptly, followed guidance and worked with healthcare professionals so appropriate action was taken.

For example, when a person became unwell, staff spotted early deterioration, followed escalation procedures and contacted emergency services. They informed relevant people, completed extra monitoring and supported the person’s recovery after hospital assessment.
 

The provider had not always ensured people were protected from avoidable harm. Shortfalls in risk management and safety monitoring meant risks were not always understood, assessed or acted on promptly.

Records did not always show that action was taken promptly in response to concerns about people’s safety and wellbeing. Safeguarding concerns were reported to the management team, but follow-up actions and monitoring were not consistently recorded or reviewed. Staff had completed safeguarding training and understood safeguarding principles, but management oversight did not always ensure people were protected from known risks.
 

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.

The provider had some processes to involve people in understanding and managing risks. For example, where risks were identified, some people received 1-to-1 support and risk assessments were updated following incidents. However, this was not applied consistently enough to demonstrate that risks were always managed in a planned and effective way.

Staff provided support that enabled people to take part in things that mattered to them, and professionals gave positive feedback about information being shared in a timely way. However, the evidence showed gaps in how risks were monitored and managed. This meant people were not always supported safely, and further improvements were needed to ensure risk management measures were consistently in place and reviewed.
 

The provider did not always identify, assess and control risks in the care environment. Systems had not ensured premises and equipment were consistently safe and suitable to support the delivery of safe care.

We visited the service to assess environmental risks following 2 related incidents. The provider had taken some action to improve safety, including introducing new window restrictors in communal areas and people’s bedrooms. However, this work had not been fully completed at the time of our assessment, despite assurances given by the interim manager and provider following the incidents.

Regular environmental checks were not effective in identifying and addressing risks. Further improvement was required to health and safety management and provider oversight to ensure people were consistently protected from avoidable harm.
 

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

The staffing rota indicated planned staffing levels were sufficient. However, further consideration was needed about how risks were managed when 1:1 support was not in place, to ensure people always remained safe.

We found staff responded quickly to peoples call bells and people told us that “staff work hard” and “nothing is too much trouble.”
 

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 IPC training, had access to appropriate Personal Protective Equipment (PPE) and cleaning products were seen to be stored safely. Communal areas and bedrooms were clean and smelt fresh. We observed staff supporting people to clean their hands.

Processes were in place and staff were clear about their responsibilities to act if they noticed any concerns in relation to infection control. Monthly audits were undertaken and any concerns were addressed within appropriate timescales to meet compliance.
 

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.