James Dixon 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.

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.

Staff confirmed they had received a thorough induction, regular supervision, and ongoing training to support them in their roles. An action plan was in place to address identified improvements and ensure continuous development. Complaints were managed promptly and appropriately, with clear processes for resolution. The provider fostered a positive and transparent approach to safety, encouraging staff to raise any concerns without fear. Staff were aware how to record any incidents and accidents, and this was reviewed by the management team.

The provider worked closely with people living there and healthcare professionals to keep care safe and well-organised. They made sure people received consistent support, even when moving between different services. The provider held weekly meetings with different agencies to share information and make sure care was tailored to each person’s changing needs.

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. Relatives and people told us they felt safe. One relative we spoke with stated, “I can sleep at night knowing whatever happens to [Name] they are safe.” One person we spoke with told us, “I feel very safe here, it’s a wonderful place.”

Staff were aware of the whistleblowing and safeguarding policy and felt confident in using it if required.

The provider did not always ensure people were involved in devising their risk assessments. Some people did not have a risk assessment in place, and some care plans did not provide staff with clear guidance on how to minimise risks or recognise symptoms. This included people living with diabetes, whose care plans were not reflective of their needs.

The registered manager responded promptly, and care plans and risk assessments were either updated or implemented. Despite these issues, staff delivered care that was safe, supportive, and enabled people to take part in activities that mattered to them.

The provider did not consistently identify and manage potential risks within the care environment. Equipment, facilities, and technology were not always used in ways that supported the safe delivery of care.

Although health and safety checks were carried out when concerns were identified, actions taken were not always recorded. For example, we found some water temperature records in bedrooms indicated a potential scalding risk. This was discussed with the registered manager, who informed us an external contractor had assessed the water temperatures and found no issues. A replacement thermometer was subsequently purchased to ensure accurate recordings.

Additionally, fire drills were not being conducted in accordance with the service’s own policy. As a result, we were not assured staff were adequately prepared to evacuate people safely in an emergency. The provider assured CQC they had planned fire drills, to ensure staff knew how to evacuate people safely in the event of a fire breaking out.

The provider did not always make sure there were enough qualified, skilled and experienced staff. We identified some staff were undertaking roles they had not received training for example some care staff were providing catheter care including emptying catheter bags without having received any training. Practical training in moving and handling was limited, resulting in a reliance on other staff members to demonstrate the use of specific equipment. One staff member we spoke with told us, “If I don’t know how to use equipment, I will ask one of the therapists to show me.”

The registered manager informed us the home was adequately staffed to meet the needs of people living within James Dixons Court however, not all staff members agreed. One staff member told us care was not always effective when there were fewer staff available to support people.

Safe recruitment processes were in place and were being followed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We found areas within the home that required cleaning and some damaged furniture and walls. The manager informed us they were aware of the concerns and there was a home improvement plan in place. There was evidence 4 rooms had been decorated with the plan for more.

The provider did not always ensure medicines were managed safely. We identified a controlled drug was being stored securely; however, records indicated it had been returned to the pharmacy. We found discrepancies in medicine counts and observed some medicine bottle labels were unreadable. Additionally, entries in the controlled drugs register requiring two signatures did not consistently have both. These issues were discussed with the registered manager and provider, and immediate actions were taken to investigate and action the concerns raised. We have been informed the provider was now working with Sefton medicines management team to mitigate future risks.