Toray Pines Care Home

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.

This is the first assessment for this newly registered service. This key question has been rated 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.

There was clear evidence that staff learned from events and implemented changes to practice. Senior staff involved in medication errors had been retrained or reassigned, and safeguarding concerns such as the progression of pressure damage were fully investigated with learning used to improve care. External support had also been brought in to strengthen staff skills, particularly around dementia communication.

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 told us there had been a good handover when people moved into the home, and care plans were put together quickly so staff knew how to support people safely. The team collected information from GPs, hospital discharge notes and other professionals to make sure they had everything they needed before people arrived. Daily handovers and oversight meetings helped staff stay updated on any risks or changes, and this meant people received safe care from the moment they moved in.

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 with CQC and the local authority.

People’s relatives told us they felt people were safe at the home. One relative said, “[Name] is secure in the areas they are in. They use a sensor mat for [Name] in their room, that makes them safe.”

Safeguarding concerns had been raised appropriately, fully investigated and used to make improvements that helped keep people safe. Staff had completed safeguarding training and were able to explain how they would raise concerns if they were worried about someone.

Authorisations under the Deprivation of Liberty Safeguards (DoLS) were in place for people who needed them, and the home had systems to monitor expiry dates and reapply when required. The service also had up‑to‑date policies for safeguarding, raising concerns, freedom to speak up and whistleblowing, which supported staff to report issues confidently.

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.

Relatives told us staff identified and managed risks. One relative commented, “[Name] has had a fall but they now have rails at the side of their bed to reduce that risk.”

People were involved in managing their own risks, and staff used clear information to keep people safe. Personal Emergency Evacuation Plans (PEEPs) were in place, and care plans included guidance to help staff understand people’s distressed reactions and how to support each person as an individual. Risks such as pressure care were clearly recorded, and appropriate equipment was in place where needed to reduce harm. The home also supported positive risk taking. For example, one person chose to use bed rails in a way that differed from good practice guidance, and this decision was respected and clearly documented as their choice.

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 safely maintained, with window restrictors in place and wardrobes securely fixed to walls. Systems were in place to manage environmental risks, such as regular legionella testing, and equipment used in the home was monitored and serviced in line with manufacturers’ guidance to make sure it was safe for people. The home was being redecorated to keep standards high, and ongoing work was taking place to create a more dementia‑friendly environment so people could feel calm and engage with meaningful items around the home.

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.

Relatives told us they were happy with the support received from staff. One relative told us, “The carers, I can’t fault them.” Another relative said, “I do really like the staff. They are all genuine caring people.”

Staff had received ongoing training and support, including extra training for senior staff, so they had the skills needed to provide safe care. Some relatives had raised concerns about staffing levels. One relative said, “It can be a little bit thin on the ground if you need help. I think it has the potential to affect [Name’s] care.” The home used a dependency tool which showed staffing was arranged in line with people’s needs, and call bell audits showed most calls were answered quickly. So while there was a perception amongst relatives that more staff were needed, people had been receiving care in a timely manner.

Staff told us they felt supported and had regular opportunities to update their knowledge. The provider also ensured staff were safely recruited, including completing Disclosure and Barring Service (DBS) checks, which looked at an applicant’s criminal record and confirmed they were safe to work with people living in the home.

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.

Relatives had mixed views about the cleanliness of the home. One relative told us, “It is very good, they are always cleaning it. No bad smells.” While another said, “There is sometimes a smell but they do try to clean it up.” The home was clean and free from odours when we visited.

Staff were clear about how and when to use personal protective equipment (PPE) to keep people safe. There was a cleaning schedule in place, and infection prevention and control audits had been completed regularly, with action taken whenever issues were identified, such as replacing equipment to maintain good standards. These systems helped ensure safe infection prevention practices were consistently followed throughout the home.

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.

Medicines were generally managed safely, although one medicine, Alendronic Acid, had not been given in line with the prescription; the schedule was corrected on the day of the inspection.

PRN (as‑needed) medicines had clear protocols in place so staff knew when they should be given and what signs to look for. Guidance from the pharmacy supported safe covert administration, and mental capacity assessments and best‑interest decisions were in place where needed. Issues with medicines storage were also addressed, the downstairs medicines fridge had not been locked and was removed, and the key for the upstairs fridge was moved onto the medicines keyring.

Regular audits were in place to monitor medicines practice and ensure improvements were made where needed.