Saffron House

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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

We assessed a limited number of quality statements in the safe key question. The scores for these areas have been combined with scores based on the rating from the last inspection, which was inadequate. We identified shortfalls with the deployment of staff to ensure people were consistently provided with timely, effective care and support. Staff did not always demonstrate an understanding of potential restrictions for people in removing mobility aids from them once they were seated. We observed staff did not always follow best practice in supporting people to transfer or mobilise. There was a lack of oversight in the monitoring of a persons' health condition. People's care plans were in the process of being updated with some care plans containing contradictory information about people's needs. We found variance in the standard of staff record keeping, which meant people's care records did not always evidence the care provided or support effective monitoring of peoples' needs. The registered manager was aware of these concerns and addressed immediate concerns during this assessment. There were notable improvements to the management of people's medicines and standards of hygiene and cleanliness. Medicines were given as prescribed and there were clear records to demonstrate this. There was a process for medicines to be administered covertly, including mental capacity assessments and obtaining pharmaceutical advice from an appropriate healthcare professional. There were clear records in place to describe any allergies and full medicine audits were recorded. The provider had made sufficient improvements to the management and administration of medicines and was no longer in breach of regulation 12. The provider was undertaking a redecoration plan which was in progress at the time of our assessment. Staff continued to be recruited safely.

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 told us they felt safe in the service and were able to raise concerns with staff if they needed to. Relatives felt staff listened and took action if their family member was at risk or following incidents. A relative described how their family member had experienced falls and how staff had taken action to assess their needs and the environment which had resulted in them having no further falls.

Staff described improvements in management and leadership which meant they felt listened to and action was taken in response to concerns. They gave examples around increased resources and more effective support from managers for staff. A staff member told us, “Previously we would ask for something and just receive a non-committal response or a ‘no’ with no explanation. Now we receive a positive response or if it’s a ‘no’ we are supported to understand why something is not possible.” Staff felt confident to go to managers to share concerns or information. Senior staff were able to contribute to daily meetings with heads of department and the registered manager which supported information sharing and learning across the service.

Processes were in place to monitor standards and identify, record and learn from incidents that happened within the home. For example, the registered manager told us learning from incidents, errors or concerns was discussed in team meetings and staff confirmed this. Actions taken and learning were documented and reviewed. For example, the registered manager had undertaken an analysis of falls within the service to identify any trends and patterns and ensure appropriate, timely action had been taken to keep people safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at the service overall, although 2 people noted the behaviour of another person made them feel vulnerable. Staff were aware of this and took measures to keep people safe and reassure people. People’s relatives felt their family members were safe at the service. People appeared comfortable around staff. People and their relatives told us they were able to speak with staff if they had concerns.

Staff received training about how to recognise and respond to safeguarding concerns. The staff we asked demonstrated an understanding of safeguarding principles. However, we saw staff had limited understanding around restrictions in their practice of removing walking aids from people once they were seated. Staff told us they did not have concerns about the safety of people using the service.

We observed staff did not demonstrate consistent approaches or understanding around supporting people with risks and keeping people safe from harm. For example, staff did not identify restrictive practices in taking people’s walking aids away from them once they were seated. Staff did not always apply a proportionate approach in balancing people’s safety or respect people’s capacity to make decisions

The provider's safeguarding policies reflected relevant legislation. The management team worked with external agencies and acted in a timely way to make sure people were appropriately safeguarded. The registered manager demonstrated their understanding of safeguarding procedures and told us about safeguarding concerns they had investigated and reported to the local authority. CQC had been notified and appropriate referrals made. The Mental Capacity Act 2005 provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. People’s capacity to make decisions was assessed and recorded.

People told us they were well cared for. Staff were attentive to their needs and responded quickly when they rang their call bell or requested assistance. People and their relatives shared examples where staff took action to keep people safe. A relative told us staff had consulted with them to install a sensor mat in their family member’s room to alert them if they got up. They told us they periodically tested this by stepping on the mat when they visited and staff always attended in a timely manner. This provided reassurance that their family member was kept safe. A person described how staff respected their choice as to how much they wanted to do for themselves and where they wanted to spend their time. They told us, “They understand and respect my choices.”

Staff knew people well and confirmed they had access to people’s care plans and risk assessments via the provider’s digital social care record system. A staff member told us, “We keep people safe here because there is guidance and information in people’s care plans and risk assessments which we follow. Mental capacity assessments are carried out for each person. This is to make sure we work as we should in protecting rights and their safety”. Further work was needed to ensure care plans were kept up to date and fully reflective of people’s needs to provide staff with accurate information and guidance, and to support positive risk taking. The registered manager told us work had already begun to update care plans and records.

We saw that although appropriate equipment was available to keep people safe, this was not always made available for people. We saw staff take people’s mobility aids away from them once they were seated in communal areas which meant people were being restricted from movement as they had to wait for staff to be available to bring the aids to them. We observed one person challenged staff and told them they wanted to keep their walking aid by their side. Staff argued against this but the person was adamant and kept their aid. Other people who were not able to stand their ground had their aids taken away. A person told us, “ I don’t know why they [staff] take my walker away and put it across the room with the others. I would prefer to keep it by my side, but they don’t let me.” We observed staff providing unsafe assistance for a person who was struggling to stand. Staff failed to adapt to the person’s ability and were seen to support the person to get to their feet by pushing them up from their bottom. We reported this concern to the registered manager. We did see other staff following safe practices when supporting people to move or transfer, including safe transfers using a hoist. We observed a person experience a succession of what appeared to be seizures without staff present. We raised this as a concern to the registered manager. They told us the person had recently moved to the service and family had only recently revealed a history of seizure activity. They had made a referral to neurology through the GP and implemented seizure diary. However, as there were periods where staff were not present in the communal areas, this meant there was no effective monitoring of this health condition.

Since our last inspection, the provider had implemented several actions to help improve their systems to monitor and manage people's risks. For example, peoples care plans and risk assessments had been reviewed and updates were in progress. We found care plans were mainly detailed and reflected people's care needs and the measures required to mitigate people's risks. However, some care plans for people contained contradicting information. For example, some sections of a persons' care plan advised staff to support them to drink through a straw to reduce the risk of choking, whilst other sections referred to a lidded beaker. A person had recently been diagnosed with a health condition that required consistent monitoring to support care and treatment. Although recording systems had been implemented and risk assessments updated, staff had not implemented monitoring and oversight which meant the health condition was not effectively monitored. We raised this with the registered manager as a concern. Staff completed daily care notes and monitoring forms to support oversight of risk, however we found records were not consistently completed. For example, re positioning charts did not always align with required frequency of repositioning within people’s care plans to maintain good skin integrity. Staff did not always accurately record the well being of a person other than ‘needed lots of help’. They failed to provide an explanation as to why they needed lots of help and what this help looked like to support effective monitoring of the person health needs.

People and their relatives were mostly happy with the environment, though some people were concerned about the lack of access to call bells. A person told us, “there are call bell points around the (communal) room but they are on the wall and I wouldn’t able to get up and push the button to get help; I would have to wait for someone or rely on someone else pushing it.”

Staff received training to keep people safe in the service, such as fire safety and health and safety awareness. The registered manager told us that maintaining the premises had been an ongoing challenge, however the recent recruitment of additional maintenance staff had meant improvements had been made. This helped staff deliver safe and effective support to people. Staff confirmed the environment was well maintained and they had enough equipment to support people safely. The registered manager shared with us the improvements that had been made and were in progress including redecoration of the service.

Improvements had been made to the environment since our last inspection and people’s care was provided in an environment which was mostly in good decorative condition. We found although call bells were located in all rooms, these were not always accessible for people. Improvements were in progress at the time of our assessment, including redecorating and changes in décor. There was an ongoing programme of maintenance and improvement in place to ensure the building, fixtures and equipment continued to be kept in good working order.

The registered manager completed audits of the property and health and safety. Regular health and safety checks and testing was undertaken to ensure the premises and equipment were safe. Actions identified were recorded on the service improvement plan.

People told us there were usually enough staff deployed to meet their needs, though many had experienced occasions when they felt the service was short staffed and had had to wait for support with personal care. One person told us they sometimes found it difficult to get a drink because staff were so busy and a second person told us they did not always get a shower when they wanted because staff were not available. Some people told us staff did not always provide personalised care. One person described how staff continued to bring them a meal that they did not like despite the person reminding them they didn’t like it (we observed this) A second person told us, “On the whole staff are great and help me. There is one staff member who always shouts at people and at staff, they shout a lot. I don’t like this.”

Staff felt there were sufficient staff deployed to keep people safe and meet their needs, though they felt there were times when they struggled to meet people’s needs in a timely way. Staff felt critical times were in the afternoon/evening when people became more active and required more interventions and support with personal care, particularly where people required 2-1 support. The provider had a dependency tool which they used to calculate staffing hours required to meet people’s collective and individual needs. They told us they were currently over-staffed given the current occupancy levels which had resulted in a significant reduction of agency staff. This in turn had improved the consistency in care people received. Housekeeping staff told us the provider had allocated more resources as a result there had been improvements in the standards of housekeeping, cleanliness and hygiene within the service.

We observed times when there was a lack of staff presence in communal areas where people were sitting of up to 20 minutes. In one lounge, people told us they were unable to reach the buttons for the care call and had to wait until staff appeared if they needed help. Additionally, we observed numerous occasions during our visit where staff walked into communal areas or through these areas without any engagement or interaction with people. Staff failed to make use of opportunities to have meaningful engagement with people outside of tasks, such as supporting with personal care. We also observed some staff lacked communication (variance in approaches and communications) skills to protect people’s dignity during conversations. For example, some staff asked if people wanted to go to the toilet in a loud voice that could be heard across the room whilst others used more discreet conversation.

Staffing levels were altered as and when people’s needs changed to make sure they received consistently safe support which met their needs. Staff were recruited safely by the provider, and relevant checks were carried out before new staff started working at the service. This included criminal record and employment checks to confirm staff were suitable to care for people. Systems and processes were in place to monitor and ensure training and supervision were up to date

People were happy with the hygiene and cleanliness of the service. People told us, "My room is always clean; they (staff) do it every day" and "I am happy they keep my room clean and tidy." Relatives were mostly happy with the standards of hygiene but felt some areas of the service were 'tired and shabby'. A re-decorating programme was in progress at the time of our assessment.

Leaders had worked with local authority IPC teams and achieved a good level of compliance which reflected the improvements made. Staff felt confident in IPC procedures and housekeeping staff reported an improvement in standards overall through increased resources, oversight and support. Further improvements were needed to establish effective working relationships between care and housekeeping staff.

Observation: provider had made improvements to hygiene and cleanliness, no malodours and overall good state of repair, staff observed to be following safe IPC procedures including doffing and donning of personal protective equipment (PPE) including gloves. PPE stations available throughout the service, well stocked and accessible.

The provider had made significant improvements to the prevention and control of infections within the service. This was recognised in infection prevention and control audits undertaken by external agencies who had no concerns. The provider had increased resources in housekeeping and implemented more robust oversight and auditing of cleanliness and hygiene within the service. Staff competencies and spot checks were completed to ensure staff fully understood their responsibilities and were followed best practice.

People and their relatives were positive when talking to us about their experience of staff supporting them with their medicines. People's comments included, "I get my pills from the staff; it all seems alright as far as I know" and " Staff give me tablets for my (health condition) and I've never any problems."

The registered manager told us they had implemented more robust systems and audits to improve the safety and administration of medicines. Staff had received medicines training and their competency to handle medicines had been assessed. Staff described how they supported people to work with healthcare professionals so their medicines were regularly reviewed.

The providers processes and policies in relation to medicine management were safe. Staff followed current and relevant professional guidance about the management of medicines. Medicines support, including administration, ordering and stock levels, were recorded accurately. If people were refusing medicines, their mental capacity was assessed, recorded and they were supported appropriately. There was a process for medicines administered covertly, including obtaining pharmaceutical advice from an appropriate healthcare professional. Governance and audit arrangements for the oversight of medicines were effective.