Goatacre Manor Care Centre

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 Requires Improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

Systems ensured accidents and incidents were investigated and appropriately reported. Any learning was discussed with staff and records showed care plan reviews were instigated, particularly in relation to falls. This ensured staff received clear guidance on how to reduce the risk of a reoccurrence.

Leaders told us they promoted an open and transparent culture, with a focus on learning and minimising reoccurrence of an event. Staff confirmed this. One staff member told us, “[Registered manager] will always relay any information that needs sharing. They are quite good at that; there isn't a blame culture here. They are keen to find out what went wrong and how to stop it happening again.”

Staff were informed of incidents and accidents and any changes to people’s care, through handovers and meetings. One staff member told us, “When I came back from a holiday, the senior carers told me about things that had happened when I was away, so I knew about any changes.”

However, care reviews had not always been undertaken in response to a person’s experience of anxiety or agitation. This did not ensure staff always had clear guidance to support people effectively at these times. Leaders told us this would be addressed moving forward.

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.

Records demonstrated the service was supported by a range of health care professionals. There were established links with local services, such as the GP surgery who routinely visited every week and more often if needed. This enabled people’s health to be monitored and their medicines to be regularly reviewed.

The registered manager and staff told us they could call the surgery for advice at any time, in addition to the GP visits. They said this was valuable, as they could be guided with treatment plans to enhance people’s health in a timely manner. Referrals to other services such as the dietician, tissue viability nurse or speech and language team, were made in response to people’s needs.

People were assessed before being offered a placement at the service. This included gaining information from any involved health and social care professionals.

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.

People told us they felt safe living at the service. One person said, “Everyone here makes me feel safe and I feel safe everywhere in the home.” A relative told us, “Safe – oh yes [my family member] is definitely safe.”

Staff understood their responsibilities to keep people safe from harm and abuse. They said they had completed safeguarding training and knew what constituted abuse. Records demonstrated staff had completed this training. One staff member said, “If I saw some bruising on someone, I would report it to the nurse. It might be neglect or abuse, so we need to check.” Records demonstrated any injuries people sustained such as bruises were clearly documented and investigated.

There was a safeguarding policy, and flowcharts which demonstrated how to report a safeguarding concern. These were readily accessible to staff. Records demonstrated leaders had oversight of safeguarding and reported concerns to the local safeguarding team as required.

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. Leaders were able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications and urgent authorisations in a timely manner.

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.

There was not always clear oversight of how risks to people’s safety were managed on a day-to-day basis. For example, some people were at risk of dehydration but monitoring records did not always show a fluid intake in line with their assessed needs. Records did not demonstrate this had been identified or escalated as a concern. Other people were at risk of pressure damage, but records did not always demonstrate their position had been changed in line with care plan guidance. Leaders told us they would implement checks to monitor these risks moving forward.

People had been assessed for risks such as skin damage, malnutrition, choking and falls. However, whilst care planning provided staff with some guidance to minimise the risks identified, it was not always comprehensive. For example, care plans for people with urinary catheters did not always include guidance for staff on how to monitor for the risks of infection.

Guidance for staff regarding risk management was often spread across different parts of the care plan. For example, information about a person’s required changes of position were documented in their skin integrity plan, but pressure relieving equipment was in their sleep plan. This made it difficult for staff to locate key information, so there was a risk it would be missed.

Staff were knowledgeable about people who were at risk of falling and how to support them safely. They understood risks such as choking and the steps they should take to reduce any incidents. This included correct positioning and any specialist guidance, which needed to be followed.

People told us they were supported to manage risks. One person said, “I have physical support either side, to get from and onto the commode and back to bed.” This minimised the risk of them falling. Another person told us they were supposed to use a walking frame but did not always use it. They said staff always asked them, “Where’s your walking frame?” This demonstrated staff’s awareness and how they promoted safety.

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

The environment was spacious, light and well maintained. Furnishing and fittings were of a good standard and made a pleasant environment for people. Safety measures such as window restrictors, and thermostatic controls to maintain water at a safe temperature, had been fitted.

There were a range of systems to ensure the safety of the building and any equipment used. This included leaders undertaking daily walk arounds, and environmental and health and safety audits. Records demonstrated regular checks of items such as the nurse call bells, fire alarms and bedrails. External contractors completed checks for legionella and serviced the passenger lift, mobile hoists and fire alarm systems.

Staff told us they alerted the maintenance person for any work which needed attention. This included call bells not working or light bulbs requiring replacement. They said any requests were completed in a timely manner. Staff told us there was an ongoing programme of redecoration, which maintained a pleasant environment for people.

Records demonstrated staff had completed training in fire safety and health and safety. Their knowledge enabled any concerns with the environment to be quickly identified and addressed.

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.

Leaders told us they used a dependency tool to calculate the numbers of staff required, combined with observations of service delivery. This enabled staff deployment to be flexible dependent on need. Leaders told us they had a good team, who covered additional shifts at time of sickness or annual leave. They said they were fully staffed and did not need to use any agency staff.

People and their relatives told us there were generally enough staff. One person told us, “I just use the buzzer and they come. Normally it’s pretty good.” However, another person said, “[Staff] say, ‘In a minute,’ but a minute goes into 5, into 10 minutes.” Leaders told us they continually monitored staffing levels to ensure people were not kept waiting but recognised there could be busy times. They told us staffing levels would be reviewed and adjusted if busy periods became routine.

We observed call bells were answered in a timely manner, and staff went about their work without rushing. They told us there were enough staff and they had a detailed induction when they started employment at the service. One staff member told us “I did shadow shifts and had time to read the care plans. I think I did a week or so of shadow shifts but could ask for more if I needed it.”

Staff told us they completed a range of training to help them undertake their role effectively. Nurses completed clinical training to enable them to maintain their registration.

However, there was not always an attention to detail within the staff recruitment process. For example, one applicant’s work history was in years, not months and there were unexplained gaps in their employment. Another application contained a reference that was addressed to ‘Whom it may concern’, not on headed paper or linked to the application form. The provider had not verified the reference was accurate. This meant the provider could not always be assured staff recruitment checks were in line with safe recruitment practice. The provider said they would ensure a more thorough recruitment process in the future.
 

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.

We observed the service was clean throughout. All bathrooms and toilets had single use soap and paper towels, and there were liners in foot operated bins. Personal protective clothing such as gloves and aprons was available and stored correctly, to minimise the risk of contamination.

Staff had undertaken training in infection prevention and control and there was a policy for staff to refer to as required. Infection control audits were undertaken and leaders observed staff practice. This ensured good practice was consistently applied.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicine administration records contained some handwritten instructions, which had not been countersigned by another member of staff. This did not ensure the instructions were correct as there was a risk of them being transcribed incorrectly. One person had been given a homely remedy without it being authorised by a GP. This was not in line with the provider’s policy, and staff could not be assured it was safe to give the person.

Some people were prescribed medicines to be taken as required. There was guidance for staff to help them administer these medicines effectively. However, the information was not sufficiently detailed or personalised. In addition, the information did not inform staff of the interventions they needed to follow before resorting to the medicines being administered. This was not in line with the provider’s policy and meant leaders could not be assured ‘as required’ medicines were administered in a person-centred way.

However, staff had consistently signed medicine administration records to demonstrate they had given people their medicines as prescribed. Staff received training in the safe administration of medicines and their competency was assessed. Staff were aware of the reporting process if an error was made.

People received their medicines in a way which met their needs and preferences. People did not raise any concerns about the administration of their medicines.