Caddington Grove

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

Systems in place at the service to monitor accidents and incidents did not always identify trends and areas for improvement. People’s risk assessments and care plans sometimes needed more detail to help guide staff how to fully mitigate risks to people. Some, aspects of how people were supported with their medicines needed improvement. The registered manager and provider told us they would review these issues and were already in the process of doing this. People’s needs were assessed before they started using the service and staff supported people to see health professionals if they needed to do so. Environmental risk assessments related to the service, including fire safety were completed and staff completed regular checks to help ensure people were kept safe. There were enough staff to support people safely at all times of the day and staff were recruited safely. Staff had the training, knowledge and supervision to be effective in their job roles. The service looked clean, and staff followed good infection and prevention control (IPC) practices.

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.

Some relatives told us they did not always feel fully informed about actions the management team took after an incident happened. One relative said, ‘‘I know at one point there was an incident and the safeguarding team were informed but we were not told what [staff] would do differently to make things better.’’ We fed specific concerns relatives had back to the registered manager and provider and they showed us evidence they had learnt lessons to keep people safe. However, they acknowledge they could improve in relation to communicating this with people’s relatives and told us they would action this. Other people and relatives gave us positive feedback about how lessons were learnt. One person said, ‘‘I feel very safe and [staff] contact [my relative] if anything happens.’’

Staff were supported to learn lessons when things went wrong. For example, the management team noted when there had been more falls reported. As a result they increased the frequency of staff meetings and discussed each incident in detail. This helped staff identify where they may be able to stop incident happening in the future. Incidents and accidents were also discussed with staff in individual and group meetings.

The provider and management team monitored incidents and accidents to identify where improvements could be made. However, these were not always effective in monitoring for trends and the systems in place did not always make it easy to identify when incidents or accidents should be reported to the CQC in line with statutory guidance. Sometimes, staff did not report incidents or accidents effectively which led to an increased risk these would be missed and lessons could then not be learnt. The registered manager acknowledged this feedback and showed us evidence of how they would put immediate improvements in place, such as reviewing the systems being used and discussing the correct reporting procedure of incidents with staff. We were assured improvements would be made.

The provider had processes and systems in place to support people effectively when they transitioned to other services such as hospitals or appointments. This included staff supporting people who needed support to communicate their needs during appointments and updating care plans and risk assessments in line with advice and guidance given by health professionals. The admissions policy at the service was thorough and helped ensure people were able to safely transition in to living at the service.

Health professionals gave us positive feedback about how staff worked with them and supported people in line with guidance they gave. One health professional said, ‘‘I have confidence that staff follow the advice we give. We are always kept informed if people’s need change and this means we can get support in place quickly.’’

The registered manager told us how they worked with other services to help make sure people’s needs were thoroughly assessed when they came to the service. Staff were confident about how to contact health professionals for support if this was needed. They also told us how advice and guidance from health professionals was shared with them and added to people’s care plans. This helped them support people in line with their current needs.

People and their relatives told us their support needs were assessed when they started to live at the service. One person said, ‘‘I moved in [on date] and am still getting used to it but all the staff have been very helpful and ask me what I would like to do.’’ Staff supported people to see health professionals such as GP’s and nurses if needed. One person told us, ‘‘The GP comes and sees us once a week and I also saw the optician recently. Staff organised the appointment for me.’’ Relatives told us they were asked for their thoughts and were a part of the assessment process when their family member started living at the service.

Policies and procedures related to safeguarding were in place. However, we found several examples where possible safeguarding events were not reported properly and were recorded in people’s daily records instead. The registered manager acknowledged they needed to improve the systems in place to monitor people’s daily records to ensure possible safeguarding incidents were reported and showed us how they were going to do this. We also found one person’s information about the support they needed with their diet was incorrect in a care plan shared with kitchen staff. This meant kitchen staff may not support the person in line with their dietary needs. The registered manager rectified this immediately. We were assured the registered manager would ensure improvements were made in relation to safeguarding at the service.

Staff were trained in safeguarding and had good knowledge about what signs to look for which may indicate abuse. They knew how to report safeguarding concerns both at the service and to external bodies such as the local authority or CQC. The registered manager showed us how safeguarding was discussed regularly with staff in meetings and supervisions.

People told us they felt safe living at the service. One person said, ‘‘I feel very safe, and the building is secure. I can call for staff support whenever I need it.’’ Relatives also felt their family members were safe living at the service. One relative told us, ‘‘I have peace of mind that [family member] is safe living at the service.’’ However, some relatives spoke with us about safeguarding events that happened to their family member, and they felt the actions taken to stop this happening again had not been fully explained to them. The registered manager acknowledged this feedback and organised to speak with relatives about this.

Staff supported people in line with their risk assessments. For example, staff used a hoist in line with a person’s risk assessment and we observed people being given safe support when staff helped them to eat and drink. People appeared happy and relaxed being supported by staff. Staff members were attentive to people and knew when they needed support. For example a staff member noted when a person was felling upset and went and spoke with them. This person smiled and started happily talking with the staff member. Staff spoke with people as they supported letting them know why they were helping them and asking if the person was happy for them to do so.

Care plans and risk assessments were detailed for the most part and gave good guidance to staff about how to support people in line with identified risks and help mitigate these. However, some risk assessments were not updated in line with people’s care plans when changes happened. The registered manager accepted this feedback and updated these risk assessments. There was no evidence people came to harm as a result of this. The provider were open and honest about how they were trying to update care plans to make them more detailed and gave some examples of where this had been completed.

People told us staff supported them in line with known risks and were confident in doing this. One person said, ‘‘I need help with getting in and out of bed and always feel safe when staff use [piece of equipment].’’ A relative told us, ‘‘I think what staff do is brilliant. They let [family member] get on with what they want to do only helping out if they think they need it.’’ People also told us they took part in regular fire drills and practice evaluations to help them get ready for any potential emergency.

Staff told us risk assessments were detailed and helped guide them to support people safely. They told us they spoke with the management team if risk assessments needed updating and this was done in a timely manner. The registered manager explained how people and relatives were asked to feedback and share their thoughts about risk assessments regularly. Staff were confident and knew what to do in the event of a fire or an emergency at the service.

Staff told us they felt safe at work and told us about the health and safety checks they carried out to help ensure the environment was safe. These included checks of moving and handling equipment and fire safety equipment. The management team completed health and safety audits of the service to help ensure it was safe. The registered manager was recruiting for a full time staff member to focus on the maintenance of the building but had support from the providers other services in the meantime.

During our inspection we observed the service to be in a good state of repair. All the equipment being used by people was checked and serviced as required. We had no concerns with the safety of the environment.

People and relatives felt the environment at the service was safe. One person said, ‘‘It is safe and secure here. This is good to know.’’ A relative said, ‘‘Every time I visit everything seems to be how it needs to be. I can see [equipment] is checked regularly. No concerns at all.’’ Relatives told us they were asked to sign in when visiting their family member. People also told us they took part in regular fire drills and practice evaluations to help them get ready for any potential emergency.

Processes such as audits and daily checks were completed by the management and staff team to help monitor and maintain the upkeep of the environment at the service. The provider had an environment improvement plan in place, based on feedback from people and staff. This plan had timescales to continue to improve the environment of the service, for example by replacing some areas of the carpeting and flooring. This would have a positive impact for people.

Staff predominantly told us they were happy with staffing levels. Some staff told us they felt there could be more staff at some points of the day, through we observed this not to be the case. Staff had the training to be effective in their job roles and were knowledgeable about this training. Staff had supervisions and meetings where they discussed their job roles and any support they needed.

We observed there to be enough staff to support people safely. People received support in a timely fashion when they asked for it or if they rang their call bells. There was a good staff presence in communal areas, but staff were also able to spend time with people in their rooms if they chose not to come to communal areas. Staff had time to sit and speak with people as well as support them with their immediate personal care and support needs.

People and relatives told us there were enough staff to support them/ their family member safely. People’s comments included, ‘‘There are plenty of staff about and I can always get hold of someone’’ and, ‘‘The staff are good and kind. They are always busy but always make the time to have a chat with you.’’ A relative said, ‘‘I cannot praise the staff enough. They have taken the time to get to know [family member] and look after them really well.’’

The management team used a dependency tool to decide how many staff were needed to support people. Rotas reflected this dependency tool and measures were in place to cover staff shortages such as sickness. The registered manager spoke positively about how they had built a strong core staff team and the plans they had to continue upskilling them to provide the best quality of care they could for people. The provider had systems in place to recruit staff in line with legislation.

We observed the service to look and smell fresh and clean. We did not identify any concerns in relation to IPC during our site visit.

People and relatives were positive about how the service was kept clean and raised no concerns with us. One person said, ‘‘[Staff] are always in here cleaning this and that. It looks nice here.’’ A relative told us, ‘‘From what I have seen the place is kept immaculately clean. I think the staff do a great job.’’

The management and staff team completed audits and checks to ensure the service was kept clean and IPC measures were effective.

Staff whose primary role was to keep the service clean told us they had enough time to complete their duties and had the equipment they needed to do this. They told us about the systems in place to help prevent IPC concerns such as the way laundry was handled. Staff felt well supported and told us they could raise any concerns with the management team.

Staff did not always record the date of opening for liquid medicines. One liquid medicine stored in the medicine trolley which had expired on 01 January 2024. Expired medicines are likely to be clinically ineffective or could cause harm. The management team carried out regular medicine audits. However, the audits failed to identify concerns related to medicines management we found during the inspection. The management team took action to address these concerns. There was a medicines policy in place and a process to follow for staff to report medicines errors and concerns.

Staff spoke confidently about how to support people with medicines. Staff stored and administered medicines in line with the prescribers instructions. They had the training and competency checks necessary to do this. Staff were supported by the local complex care team to prevent hospital admissions. We observed staff giving medicines to people in their preferred way and in a kind and caring manner.

People were not always kept safe in relation to medicines practice. People were prescribed medicines to be taken on a when required (PRN) basis. Guidance in the form of PRN protocols were not always in place to help staff give these medicines consistently. For example, there was no guidance for staff on how to administer these medicines for 2 people. Some people living at the home were administered medicines covertly. However, for one person the best interest decision form was not signed by their GP. For another person, the staff did not seek advice from the pharmacist to make sure medicines remained safe and effective when prescribed for administration covertly. The registered manager addressed these concerns in a timely manner. People and relatives told us they had no concerns about how they were supported with medicines.