Salisbury Manor

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 75 (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.

Incidents were recorded and reviewed. Records were monitored by the registered manager and the provider. Information was stored on an electronic system which provided the registered manager with a ‘dashboard’. This enabled them to see at a glance high level information about what was happening at the service. The registered manager completed a monthly analysis of incidents to identify themes or trends. Learning was discussed with staff in meetings and individually in supervisions. Staff said they were involved in learning from incidents and able to reflect on how to prevent recurrence. One member of staff said, “There is definitely a no blame culture here, they [leaders] support us to learn from issues and mistakes.”

The provider shared updates with leaders and staff about incidents and events that happened in other services they managed. The regional director shared learning from other services in regular managers meetings held for the region. This helped create a culture of information sharing, learning and openness.

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.

The provider had documentation which staff used to go with a person if they went into hospital. This enabled key information to be shared with healthcare professionals. If needed, the person’s medicines also went with them which ensured a continuity of care for people.

The registered manager told us depending on the length of stay in hospital a re-assessment of people’s needs would be completed. Nursing staff communicated with healthcare professionals on discharge to check for changes to people’s needs or changes to medicines. Staff monitored people’s skin on discharge and checked for any pressure damage. Staff also checked if people had infections which were also recorded and monitored. Staff had regular handovers which helped them keep up to date with people’s movements and any changes.

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. People told us they felt safe at the service.

Information on safeguarding people was available around the service on notice boards. Staff understood their responsibilities and knew where to report any safeguarding concerns. Staff had training on safeguarding and had regular refreshers. One member of staff told us, “I have done the training. I am confident managers would act on any issues raised. We have details of CQC and the local authority contacts as well as contacts in Care UK.”

Leaders knew to share concerns with the local authority. The provider had systems to make sure all safeguarding incidents were shared. For example, an internal quality check identified some incidents which had not been shared with the local authority in a timely way. The registered manager took action to address this shortfall.

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 service was following the DoLS process and had applied to the local authority appropriately for people who lacked capacity. For those DoLS that had been authorised, the service was meeting conditions.

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.

Risks to people’s safety had been assessed prior to admission and guidance was recorded for staff to follow. Risk management plans were reviewed regularly and updated if people’s needs changed. Staff were knowledgeable about people’s needs, and we observed them supporting people as per risk management plan guidance.

Leaders did monthly monitoring of risks such as falls. Analysis was completed to identify trends or areas that could be improved. Leaders had a good understanding of actions that could help reduce risks to people’s safety. For example, leaders told us people being engaged in activities was a factor to help reduce the risk of falls. Clinical governance meetings were held to enable nursing staff and leaders monitor risks and discuss actions to reduce risks to people’s safety. This helped make sure all risk reduction measures were identified and implemented.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety checks were completed regularly. This included checks on-site carried out by maintenance staff and checks completed by external contractors. Facilities such as fire systems were tested weekly and staff completed regular fire drills. Water systems were regularly monitored to reduce the risks of Legionella. Records demonstrated all areas of the environment were serviced and checked.

Staff used a range of equipment to support people. This included hoists, profiling beds, aids to help people stand and sensor equipment to help monitor people’s movements. This was used when people had an identified risk of falling. We observed staff using equipment safely and appropriately. All equipment was clean and had been checked for safety.

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.

New staff had an induction and opportunity to shadow other more experienced staff. Training was provided in a wide range of subjects including moving and handling and dementia. During our inspection we saw a face-to-face dementia training session was being held for staff. This enabled staff to discuss dementia care with other staff and a specialist trainer which promoted understanding.

Staff had been recruited following pre-employment checks. We did find 1 recruitment check which had not been explored for more information. The registered manager took immediate action to address this during the inspection.

Overall feedback about staffing numbers was that there were mostly enough staff, but when there was short notice sickness, this created concerns at times. One member of staff said, “We have enough staff generally. We do have some problems when people call in sick, but it is usually covered. I don’t feel it becomes unsafe.” Some relatives said they would like to see more staff available. We shared this feedback with the registered manager and provider.

The provider used a dependency tool to help calculate staffing numbers. At the time of this inspection the service was overstaffed according to the calculations. We found there were enough staff to safely meet people’s needs. Staff were available to support people in a timely way; call bells were being answered and staff had time to sit with people.

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 throughout, and schedules helped domestic staff make sure all areas of the service were thoroughly cleaned regularly. Staff had personal protective equipment, and we observed them using this safely.

Regular quality checks were completed for infection prevention and control to identify any areas that could be developed or improved.

People and relatives said the service was always clean. One relative said, “Salisbury Manor is always clean, tidy and without odours.”

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 had their medicines as prescribed and did not share any concerns about how their medicines were managed. Medicines administration records demonstrated people’s medicines were consistently administered. We found no gaps in recording. Where people had been prescribed ‘as required’ medicines, there were protocols available to guide staff on administering this type of medicine.

The service used tools to help monitor people’s pain. This meant if people were not able to verbalise they were experiencing pain, staff could use observation tools. This helped to make sure people had their pain relief when they needed it. Medicines were stored safely.

Staff had training on medicines management and assessments for competence. People told us they had no concerns with how their medicines were managed and received them regularly.