Smallbrook 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

We identified two breaches of the legal regulations. The risks associated with people’s care was not always being managed in a safe way and there was not always sufficient staff deployed to support people in a safe way. There was a lack of analysis of themes and trends when people had fallen however other actions had been taken to reduce other risks to people. Staff had been recruited safely and people said they felt safe with staff. Detailed assessments of people’s needs took place before they moved into the service. Appropriate safety checks were undertaken with the environment and the equipment being used to support people. During our assessment of this key question, we found concerns around the management of people's falls and the risk associated with their care. You can find more details of our concerns in the evidence category findings below.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Clinical risk meetings were taking place where all areas of care were reviewed including wounds, health issues, people’s anxieties and accidents and incidents. However, we found that although a root cause analysis was undertaken to review why a person had fallen, there was no overall analysis of themes and trends to consider whether other areas could be a factor including staff deployment. We found falls had increased in March 2024, the majority of which were unwitnessed.

People and relatives told us at times things would change when incidents or events of concern occurred, but this was not consistent. One person told us they were not happy with the size of meal portions but felt they were not listened to, and no changes had been made as a result.

Staff fed back they knew how to respond to incidents and accidents. One told us, “We have a regular flash meeting for the heads of each department every day and we have a monthly staff meeting with individuals with each department. The meetings are useful.” However, they said that sufficient action was not always taken to reduce further risks to people particularly if they had fallen. One member of staff said, “Some of the falls can be prevented.” The registered manager and senior staff told us they had weekly clinical risk meetings. The registered manager told us, “I saw the number of falls, I needed to see how we can prevent and what we can do. There are people with dementia, dizziness and more independent.”

People and relatives told us a detailed assessment of people’s needs was undertaken before they were admitted to the service. Comments included, “[Staff] agreed to do the assessment overnight and everything was very well-organised, they contacted (the other place the person was staying in) to gather all information” and “The hospital did the assessment and staff (from Smallbrook) went to hospital to see them.”

The registered manager and senior staff told us they visited people in their own homes or at hospital do to an assessment to ensure they could meet the person’s needs. The registered manager told us, “I do the pre-assessment. We look at all medical background. We go to the home or hospital. We have 13-page document. I come and talk to the team, we look at if I need equipment and if we have this in place, this is before they come." Staff told us they were made aware of the person’s needs before they moved in, so they were aware of the care that needed to be provided. One told us, “Our seniors will explain what we need to do.”

We found the pre-admission assessments were comprehensive and included information on some preferences, care needs, contact information and health needs. Staff then reviewed this information once people had moved in to determine whether any changes needed to be made.

People told us they felt safe at the service. Comments included. “It is safe, and we are looked after well”, “I feel safe, the atmosphere and the staff are very good” and “Staff are caring and nice.” Relatives also fed back they felt their loved ones were safe and felt assured when they returned home from visiting them. One told us, “Staff always treat [person] and others with respect.”

The provider had a safeguarding policy in place and had received training. There was information around the service to remind and guide staff on how to report concerns. Where incidents of safeguarding had occurred, these were reported to the Local Authority and appropriate investigations took place.

During the site visit, staff, without exception, were polite and caring towards people. We observed people did not hesitate to approach staff and looked comfortable in their presence. We did not observe any safeguarding concerns during the visit to the home.

Staff had a good understanding of possible signs of abuse and what actions to take if they suspected abuse. One member of staff told us, “Regarding physical abuse, you might find bruises on residents. I would document it. I will ask the resident how it happened if they have capacity. I will speak to the staff who helped the resident. When we do personal care, we monitor the body. If there are bruises or anything new.” A senior member of staff told us they were safeguarding lead in the service. They said, “It’s me who is dealing with all the safeguarding. If it’s something I can’t do, I will ask the advice of the manager or [nominated individual].”

People and their relatives told us staff knew how to support people safely. One person told us when they had a shower, staff were there to support them, so they did not fall. Relatives’ comments included, “Staff got GP [involved] in time and [person] has antibiotics (for infection)” and “Staff know him [and his needs], equipment he requires is here.”

Where people were at risk of dehydration and malnutrition there were no targets set for fluid intake. Portion sizes for meals were also not recorded for meals. The provider has addressed this. The provider had not ensured the risk assessments had detailed guidance for staff. For example, 1 care plan stated the person may present with high levels of anxiety but there was a lack of guidance on how staff were to support them with this. Where people were unable to use their call bells due to their cognition there were no risk assessments in place with guidance for staff on how best to manage this.

One person was supposed to be supported by staff when eating and drinking due to the risk of choking. We found staff were not always with the person when they had a drink and we observed the person coughing. The registered manager told us they will remind staff that staff need to be present. Other areas of risk were managed well. We observed people had their call bells and their walking aids within reach. We observed people had low beds to reduce the risks of them falling out of bed. Where people required modified diets, this was being provided.

Staff told us they were aware of the risks associated with people’s care and how to ensure they get people safe. One member of staff told us, “We make sure all sensor mats are in place. We go and check on them every hour." Senior staff told us they review people’s risk assessments monthly or more frequently if a need has changed. One told us, “We have a list of the resident of the day. Care plans and risk assessments will be updated and we have to look on the other areas as well. All of us are involved. If seniors are unable to finish, they will pass to the senior at night.”

During the visit we found the sluice rooms had been left open and accessible to people. The rooms were cluttered and in needs of some maintenance. There were rooms where hazardous materials had been left out, accessible to people including hair dressing products and people’s prescribed creams. Since the inspection we have been told this has been addressed. We found overall the environment was free of clutter downstairs and upstairs. People had any necessary equipment with them where needed.

There were audits in place to check the safety of equipment and the building. In the event of an emergency such as a fire each person had a personal evacuation plan. These were left in the office and could be accessed quickly and easily if needed.

People told us they liked the environment and had plenty of space in their rooms. Relatives told us there were lounges they could use when visiting their loved ones.

Staff told us how they would ensure the environment was safe for people. One told us, “We make sure there is sufficient light to see where they are going and for us to see they are still safe." Staff were aware of the fire safety procedures in the event of an emergency. The registered manager told us, “The equipment audit is undertaken by maintenance. Staff identify anything broken then I will organise this straight away. All the risk assessments around the building will be undertaken.”

The majority of staff raised concerns about the staff levels or the deployment of staff. Comments included, “We always have a task to do. If we are three staff (at night) we try to give a wash to 20 people, but we don’t get time”, “Nighttime we need more staff” and “We are not giving it 100% and it takes a lot of time to give them a nice wash they deserve.” Staff told us they felt the training was sufficient and were able to have one to one meetings with their manager. One member of staff said, “Induction was informative, they taught me everything I need to know. Online and moving and handling in person.” Another said, “I did 2 weeks of shadowing and online training.” The registered manager told us the staff levels were based on the numbers of people and their needs. They said, “When [staff call in] sick, we cover with a senior and they cover the shift." They said of supervisions, “Supervisions should be every 2- 3 months or unless we need to speak to the them."

People and relatives said at times there were not enough staff to support them. Comments included, “Staff are extremely busy all of the time, but they are helpful” and, “They could do with some more. I only use the call bell in an emergency. Sometimes I get up to the toilet on my own as I don’t have time to wait.” People also told us at times, staff would come and switch off their call alarm and leave the room again without providing the support them needed. People and relatives fed back however that staff were competent in their role and felt they were trained well.

There were multiple staff around downstairs during the day. People were attended to throughout the day when needed, although carers were busy supporting with tasks, there was limited interaction with people in the lounge and when some were walking around the downstairs corridors.

We found people were not always given choices around when they wanted to have a shower or a bath. We saw there was a schedule in place in the laundry where it indicated people were allocated 2 showers a week and we confirmed this by looking at the people’s care notes. We noted that despite the registered manager telling us there are always 4 staff on duty at night, the rotas showed 8 nights since 18 March 2024 where there were only 3 staff working. Prior to this when 3 staff were required, there were 2 nights in February and 1 night in March 2024 where only 2 staff were on duty. We also identified that at times staff were working long hours that risked fatigue and mistakes happening. There were occasions staff were working 6 days in a row of 12-hour shifts. One member of staff worked 7 days in a row which also included a night duty. We saw from records that staff were routinely recording the night staff had given personal care to people before they went off duty but not recording whether they needed to wake the person up. This linked to staff telling us they woke people up to provide personal care before they finished their shift.

Staff completed infection control training and there were policies in place in relation to infection control. Audits were taking place however this was not always effective in identifying the concerns we found although this was resolved when raised with the provider.

People and relatives fed back they felt the service was clean and tidy.

Staff were able to tell us how they reduced the risk of infections with good infection control practices. One member of staff said, “There is enough PPE[Personal Protective Equipment]. It’s clean.” However staff also fed back that at night their duties were to clean and do laundry on top of supporting people which they said can be a struggle.

There were elements of the service that required some improvement around the cleanliness. The sluice rooms that staff were accessing were dirty. There were armchairs in the lounge and 2 mattresses in people’s rooms that smelled of urine. The provider has told us this has now been addressed. Overall the home was clean, and staff were seen to wear gloves and aprons during lunch. We observed cleaning staff working throughout the day. Food plates were covered for transfer to bistro area.