Shoemaker Place

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• 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

During our assessment of this key question, we found concerns around managing medicines, systems to keep people safe, learning lessons when things go wrong and managing people’s risks. This resulted in a breach of legal regulation in relation to safe care and treatment. People were not supported to receive their medicines in a safe way. Systems in place to keep people safe were not always effective. While the staff we spoke to expressed that they knew how to identify and raise safeguarding concerns, our assessment found procedures in place to safeguard people were not always effective. People’s risks were not always managed safely. The provider did not always learn lessons when things went wrong. There were systems in place to ensure the environment was kept safe. Regular infection control audits were carried out and where problems were identified, action had been taken.

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.

People gave mixed feedback about how much they were involved in improving the service. One person said, “I’ve never been asked about the running of the care home.” Another person told us, “We attend resident’s meetings and things we discuss are actioned by staff.” We saw evidence resident’s meetings had taken place and people’s concerns had been discussed such as food variety and timings of mealtimes. Questionnaires were available in the reception area.

Staff told us there were systems in place to identify and act on safety concerns however they were not always confident the previous management would act on those concerns. One staff member told us, “I would now feel confident in raising issues which has not always been the case due to problems with previous management.” Another staff member told us, “When a resident was left too long without receiving personal care, an investigation took place and staff were spoken to about what had been learned from the incident.” The staff we spoke to told us they had attended daily handovers, team meetings and one to one meetings with management where they could discuss concerns they had about people. However, we found the provider could not always evidence investigations took place when incidents occurred and learning was not always shared with staff.

The provider did not always learn lessons when things went wrong. There were systems in place to identify when things went wrong however the provider could not evidence all incidents were investigated and where investigations had taken place, the learning was not always shared with staff. For example, incidents relating to falls, medicines and skin care. Although staff told us handovers and team meetings took place, discussions about learning from incidents were not recorded. This meant the provider could not be assured staff were learning effectively from incidents and risk was being reduced or removed. The provider had put in place a new handover process following a recommendation from the local authority who had been supporting the care home following concerns be raised about the quality of care delivered.

People told us they felt safe. One person told us, “I feel safe and comfortable here.” Another person told us, “I am safe and would speak with staff if I had any problems.”

Systems in place to keep people safe were not always effective. Staff gave mixed feedback about the systems in place to deliver safe care. For example, one staff member told us, “When somebody has had a fall, we use the emergency buzzer to request help from senior staff, check the person over and call an ambulance if we are unable to assist the person up safely.” Another staff member told us, “We need to record exactly what foods people have eaten and how much they have eaten however we do not always do this as well as we should.” One staff member told us, “If somebody has had a fall, we use the emergency buzzer to call for senior staff, check the person over and call an ambulance if we are unable to assist somebody up safely or they have injuries.” The operations manager told us the care home had put in place an improvement plan following local authority visits in which they found issues with managing safety issues. The deputy manager told us they have changed the way they do handovers to improve communication between staff.

Professionals supporting people living at Shoemaker Place gave mixed feedback about how the care home manage people’s safety. One professional told us, “I am not aware of any safety issues of concern and I feel the care home provides a good quality of care for the residents and advocates well for them when liaising with our service.” Another professional told us, “We have had to make a safeguarding referral about a person’s bruising which had not been investigated or reported by the care home.”

Systems in place to keep people safe were not always effective. Although incidents and accidents were recorded, these were not always investigated. For example we found some medicines errors had not led to investigations and actions were not put in place to reduce or remove risk. Where falls had been recorded as part of a themes and trends analysis, the analysis lacked detail and there was no record of how lessons had been learned from falls incidents. Where complaints from relatives had been investigated, the findings had not always been recorded or the lessons learned shared with the wider team. This meant people were at risk from continued harm and receiving a poor standard of care.

While the people we spoke to expressed that they were safe and had had no reason to raise any safeguarding concerns, our assessment found procedures in place to safeguard people were not always effective.

Staff understood about safeguarding procedures and whistle blowing. They explained they had undertaken training about abuse and knew how to recognise and report this. One staff member told us, “Residents are safe and happy. When issues come up, they are dealt with.” Another staff member told us, “I escalate to management if somebody comes to me with safeguarding concern. We watch staff and encourage good care and deal with issues with conduct. I know to inform local authority if I identify safeguarding concerns.

While we did not observe any incidents requiring a safeguarding response, our assessment found procedures in place to safeguard people were not always effective.

Procedures in place to safeguard people from abuse were not always effective. Although safeguarding incidents and accidents were recorded, these were not always investigated. For example, we found some safeguarding concerns about falls, medicines errors and people’s skin had not led to investigations and actions were not put in place to reduce or remove risk. This meant people were at risk from continued harm and the provider could not be assured that safeguarding incidents were being referred to external authorities when required. The safeguarding policy had been reviewed and was up-to-date.

While people gave mixed feedback about how they were supported to manage their risks, we found people’s risks were not always monitored or escalated when required. One person told us, “I use the hoist and there is always a hoist available when I need to be supported to move.” Another person told us, “I told staff I was feeling unwell but I’m still waiting to see a doctor."

While staff expressed they were knowledgeable about people’s risks and knew how to escalate concerns, we found people’s risks were not always escalated when required. One staff member told us, “We support people with their mobility, nutrition and incontinence risks and know when to escalate if there is a problem. Another staff member told us, “Some of the residents are diabetic and the chef makes sure they receive diabetic puddings.”

Where people had risks in relation to eating and drinking and mobility, we observed staff explaining to people what they were doing, delivering safe care and providing reassurance.

People’s risks were not always managed safely. Where people were had risks in relation to constipation, nutrition or behaviours care plans did not always include information about how staff should escalate concerns and health advice was not sought when required. For example, staff did not request medical support for people who had not passed a bowel movement for 6 days. Where people required their fluid intake to be monitored due to a health condition, there was no guidance about how much staff should encourage them to drink and when they should take action if they had not had sufficient fluids. Where people’s behaviours place themselves and others at risk, care plans did not include updates from other professionals and did not include information about how staff could support them to deescalate behaviours. This meant people were at risk of not having their health needs met. Although 2 kitchenettes, located in communal dining areas on both floors of the care home, had lockable cupboards and worktop mounted lockable boxes, we found they were left unlocked which meant people were at risk of accessing harmful substances such as washing up liquid and alcohol. When we reported this to the management team, the issue was addressed straight away.

People told us the care home was clean and tidy and the atmosphere was homely.

Staff told us the environment was safe and any problems they reported were addressed straight away by maintenance. One staff member told us, “It is the best care home I’ve worked at for safety of the environment.” The operations manager told us they were worked closely with contactors and followed recommendations where required. For example, the provider was exploring changing shower heads in some rooms to further reduce the risk of legionella.

People were able to move safely around the environment. There were grab rails and specialist equipment available to support people who needed these. People were provided with specialist beds, hoists, and other equipment. There were coded doors to help restrict access to stairways and front door. We fed back to the management team how similar the décor was in each part of the building which meant people with dementia might find it difficult to navigate the building without staff support.

There were systems in place to ensure the environment was kept safe. Although environmental checks were carried out, some records lacked detail about how they had been carried out. For example, records of fire drills did not always include information about which part of the building the fire drill was performed in or how long the evacuation took. Gas safety, electrical and moving and handling equipment was checked and serviced where required. Although the maintenance team did not always record tasks as having been signed off when they had been completed, we found environment safety issues were reported and addressed by maintenance in a timely way.

Although people told us there had been a lot of staff changes recently, people felt there were enough staff and staff treated them well. One person told us, “There has been a lot of staff changes, but they use consistent agency staff.” Another person told us, “There are a lot of agency staff and I’m not always sure who comes through my door.” One relative told us, “My [relative] is support by carers with washing and dressing and they allow them to be as independent as possible.”

Staff told us they had completed the required training to do their role and attend 1-1 and team meetings. One staff member told us, “I have received lots of training including face to face moving and handling training, safeguarding, nutrition, first aid and person-centred care. Another staff member told us, “We attend 1-1 and staff meetings where we discuss how we are feeling, concerns about people’s care and if we have any training needs.” While staff told us there not always enough staff in the busier periods, we found there were enough staff and the management team had responded to staff feedback by trialling an extra staff member to support with the busy morning periods to assist people to get up. Although staff had not always felt confident the management team would respond effectively to their concerns, they felt more confident the new management team would address issues raised. The operations manager told us staff had not always felt confident to raise issues with the previous management team however they were working towards a culture of openness with staff so they felt confident to raise concerns which would be dealt with.

We found there was enough staff available, and staff delivered safe care which met people’s needs.

While the provider had processes for supporting staff through regular supervision and meetings, learning from incidents was not always discussed with staff. This meant staff were not effectively supported to learn when things go wrong. When we fed back to the management team there was a low ratio of staff who had completed end of life training which meant people were at risk of not having their end-of-life needs met, the management team responded straight away and put a plan in place to ensure all staff received this training where required. The provider used a dependence tool to calculate the numbers of staff they needed and responded to recent staff feedback to increase staff numbers in busier periods. Staff were safely recruited. New staff were subject to pre-employment checks such as reviewing their education and employment history, references from previous employers and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

People told us they lived in a clean environment.

Staff told us there are infection prevention control systems in place. One staff member told us, “We have very good housekeeping staff who keep the care home clean.” Another staff member told us, “We now have colour coded systems in place to avoid cross-contamination. We get personal protective equipment (PPE) stock very quickly when we request it.” Housekeeping staff told us they had all the resources needed to keep the premises clean and disinfected.

We observed staff cleaning the environment throughout the day. The living environment looked clean and smelt fresh. The domestic cleaning trolleys were attended to by staff on the units and were well equipped. COSHH products were stored in a locked cupboard in the laundry room.

Regular infection control audits were carried out and where problems were identified, action had been taken. Staff understood about good infection prevention and control. They had training to help them understand this and followed good hand hygiene practices. There was enough personal protective equipment (PPE) and staff knew how and when to use this. The infection prevention control policy had been reviewed and was up-to-date.

While people told us they are supported to take medicines and have had no issues with how staff support them with this, people were not always told what they were taking. One person told us, “I do take medication, but I don’t know what it is for.” Another person told us, “I feel some agency staff do not know what my medication is for.”

Staff responsible for handling medicines received medicines training. One staff member told us, “I have received medicines training and learnt how to use the electronic system. Medicines audits are completed and when errors occur, we escalate to management and seek advice from the GP. While staff informed us they received medication training where required and had their skills, knowledge and competency assessed to make sure they could handle medicines safely, we found concerns with how staff stored, administered and recorded medicines.

People were not supported to receive their medicines in a safe way. We found a controlled drug stored on the medicines trolley had not been labelled. This meant people were at risk of being given the wrong medication. Where a person was prescribed as and when medication for a medical condition, there was no information in their care plan to guide staff how to manage symptoms and staff had not recorded the reasons for administering the medication. This meant the person was at risk of receiving medication when not required and being exposed to its side effects. When we fed this back to the management team, a plan was put in place straight away to investigate the concerns. Medications with used by periods, such as liquid medication, creams and inhalers, and were stored in a medication trolley, did not have the ‘opened’ dates recorded on the medication. This meant people were at risk from receiving ineffective medication. Medicine Administration Records (MAR) were completed. The provider carried out audits to ensure there were no mistakes however these did not always identify practice which put people at risk.