Cookridge 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 did not always promote people’s safety.

The service was in breach of legal regulation in relation to failures to act within accordance of the Mental Capacity Act 2005.

This service scored 62 (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.Staff told us they learnt from when things went wrong, and they had the opportunity to discuss this openly in daily stand-up meetings. There was a process in place for the recording and reporting of safety concerns, which was overseen by the registered manager. Analysis was in place to review safety events. However, further work was required to ensure staff consistently followed the provider’s falls management procedure. As this concern relates to the provider’s oversight, we have followed this up within the well led domain.

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.Staff monitored people’s health, making appropriate referrals to other healthcare providers when needed. We received positive feedback from supporting health professionals who regularly visited the service. One professional told us, “We have weekly meetings with the care home and the GP surgery which makes our relationships stronger, creating better communication, leading to better patient care.”

When people needed to access other care services a hospital emergency plan could be created to help ensure a smooth transition of care.

The provider worked with people and healthcare partners and shared concerns quickly and appropriately. Staff told us they knew how to raise concerns, and they were confident managers would deal with these concerns appropriately. The registered manager submitted appropriate safeguarding referrals to the local safeguarding team when needed and people were appropriately supported if they felt unsafe.

Appropriate Deprivation of Liberty Safeguarding (DoLS) application had been submitted, when required. However, we found these applications had not been updated when someone’s needs changed. The provider informed us that, due to delays within the local authority in processing DoLs application, they had been advised not to submit any additional requests. However, we could not be assured that all the DoLS applications sent for authorisation were accurate.We found that people were not always supported to make decisions about their lives, care and treatment in line with the Mental Capacity Act 2005 (MCA). We were not assured staff and leaders had a good understanding of the principles of the MCA. For example, people had been restricted in accessing their personal toiletries within the dementia units of the service. The provider had not completed the appropriate mental capacity assessments or best interest decisions for people who lacked capacity around this area. A blanket restriction was implemented; this was not required to keep people safe. This restriction had not been identified by the provider or registered manager. When raised at the inspection the registered manager reviewed the restriction, and this has now been lifted. However, people’s freedoms have previously been restricted without appropriate authorisation.

The provider did not always work well with people to understand and manage risks. However, staff provided care to meet people’s needs, care was supportive and enabled people to do the things that mattered to them. We found that people’s care records did not always have accurate risk assessments in place to help ensure effective risk management. For example, following a fall a person’s risk assessment had not been updated correctly. This did not reflect the person’s fall history nor was the mitigation in place to help minimise the risk to that person in the future recorded. We found that staff's knowledge varied when discussing identified risks and mitigation in place. For example, when discussing flammable creams and the risks these posed to people, staff were not aware a risk assessment was in place and could not locate these on the care planning system. Following inspector feedback, the provider updated their records to provide greater awareness and clarity to staff around the risks to people.People told us they felt safe, and staff could demonstrate how they managed risks to people. However, records did not reflect a consistent approach to risk.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.Maintenance checks were in place to help ensure people’s safety. Staff raised concerns directly with the maintenance team so these could be addressed quickly to resolve any issues. People’s rooms were personalised to suit their tastes, needs and preferences. One resident told us, “My room is lovely, I make it as homely as I want.”

More consideration was needed to ensure the service was in line with best practice guidance for people living with dementia, despite the environment was safe for those living at the service currently. However, as people’s conditions deteriorate overtime, improvements will be needed to ensure their environmental needs are met and risks remain low.

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.Staff were recruited safely with appropriate checks taking place, people had an induction and training programme to ensure they were competent and had the right skills to provide safe care.People told us they thought the staff were well trained. One person said, “I think the staff are well trained, yes, they are knowledgeable and work well together and with the residents. I find them very competent.”There was enough staff to meet the needs of the people, and the provider used a staffing tool to help calculate safe staffing numbers.

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.The service was clean, and domestic staff were on shift daily to help ensure an infection free environment. Cleaning checks were in place to help monitor the cleanliness and staff wore personal protective equipment (PPE) appropriately. When we asked people if the service was clean and well maintained, one person said, “The building is very nice, nice decorations, clean and sparkling.”

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 medication when they needed it, from staff who were confident in managing medication. Training had been provided to ensure staff had the appropriate knowledge and skills. Processes were in place for the ordering and storage of medication. Checks were taking place to ensure that medication was administered safely.