Weavers Grange

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 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.

When an accident or incident occurred, staff took appropriate action, including seeking medical attention if required. Feedback from care staff demonstrated they knew how to escalate concerns.

Effective systems were in place to identify any trends or patterns in accident and incidents so action could be taken to mitigate emerging risks. Any lessons learnt were discussed at team meetings to aid staff learning and development.

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 recently revised their admission process recruiting additional staff with relevant experience of managing the transition process. People’s needs were assessed before moving into the service to ensure they could be met.

We observed a GP visit during our inspection. Staff were able to give timely updates, although the electronic care records hindered communication as relevant reports were not always available or easy to find.

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 Cedars Place Care Home. One person said, “They look after me well here, the carers are really good, so I feel safe.” A relative said, “I consider my [relative] is living in a safe environment.”

Staff had received safeguarding training and understood their responsibilities in keeping people safe. A member of staff told us, “If I suspected harm or abuse, I would immediately report to management and document all the details.”

Records demonstrated that safeguarding incidents were referred to the local authority and Care Quality Commission appropriately.

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. However, some care plans lacked detail.

There was a balanced and proportionate approach to the management of risk. People were supported to access the local community. One person told us, “I like being outside which they accommodate me with.” A member of staff said, “There's gardens and parks very local, so we use them all the time. There's shops close by which we use often.”

Care records had been regularly reviewed and updated. Risks to people were reflected in care plans but there was not always sufficient guidance to guide staff on how to manage a situation and best support people. For example, on both inspection visits we observed a person exhibiting a behaviour which upset other people. Staff told us about this behaviour and one member of staff was particularly good and managing the situation. However, neither the behaviour nor information of how to manage it was contained in the care plan.

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

People told us that the environment was safe and met their needs. One person told us, “I like being here in the new glass enclosures by the front of the house so I can see stuff going on and it's sheltered.” A relative said, “The garden space is a real positive for the residents and relatives, and we spend as much time as we can out there. It has recently been well tidied up.”

Systems were in place to report maintenance issues and these were resolved quickly. The servicing of equipment such as lifts, hoists and fire systems was completed at the required intervals and detailed records maintained. Regular checks of equipment were recorded to ensure this was safe for people to use.

The provider had recognised that some aspects of the environment and technology had become tired and did not always support the delivery of high-quality care. There was an action plan in place which included extensive refurbishment of the premises and improvements to the electronic care planning system.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We received mixed feedback from people, relatives and staff regarding staffing levels. A relative said, “There is sufficient staff to meet my relative’s needs,” and a member of staff said, “Staffing is usually covered quite adequately on most shifts.” However, other relatives raised concerns about staffing levels. A relative told us, “It’s difficult to say if they have sufficient staff. Carers often seem very busy, and residents have to wait some timefor carers to become available to see to their needs [particularly residents asking to be escorted to the toilet].” Some staff also raised concerns with 1 person telling us, “Not enough staff. Over the last 6 months we have struggled a lot,” another member of staff said, “There is always a shortage of staff.” Relatives also gave us examples of when there had been no staff in the lounge areas and when their relative had not been supported with personal care in a reasonable time scale.

We discussed the concerns with the manager and chief executive officer (CEO). They told us that the staffing issues had been recognised and addressed. They were actively recruiting both care staff and nursing staff. They had increased staff benefits to attract high quality staff. This was confirmed when a member of staff told us, “Currently I do not think that there are enough staff it is something that I brought to the attention of the CEO very soon after joining, the regional manager had already escalated this and the impact that it could have on the care. The CEO was very responsive and increased the staffing matrix and immediately started advertising for the roles.”

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.

Feedback from the majority of people and relatives was that the service was kept clean. A relative said, “The environment feels safe and always looks very clean.”

The provider had an infection control policy and procedures in place to manage infections. Regular infection prevention control (IPC) audits were carried out to check compliance with the policy. Staff received training in IPC practice and the use of personal protective equipment (PPE). Care staff confirmed that PPE was readily available.

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 stored securely, and records of medicines held by the service matched the stock levels. Protocols were in place for medicines prescribed for use ‘as and when required’ although some were incomplete.

For 1 person their records demonstrated a reduction in their PRN morphine due to their wound healing. Body maps were used to guide staff when administering topical medicines.

People were supported to take their medicines safely by staff who had received training to do so. Medicines administration rounds took a long time but were consistent. There were systems in place to check medicines were being managed safely, this included completing audits and checking staff competency.