Cockington House

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 requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider was in breach of a legal regulation in relation to safe care and treatment.

This service scored 50 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

We identified safety concerns at our previous inspection which had not been addressed. The provider had an external risk assessment completed regarding fire safety but had not actioned recommendations to improve safety in the home.

We had received concerns regarding a closed culture at the service and considered how risks associated with this were mitigated. However, we found no concerns regarding closed culture, staff and managers were open, honest, and communicated effectively with the inspection team.

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.

We saw evidence that people were assisted to access support from health professionals, for example the GP and psychiatrist, and people we spoke with supported these findings.

The provider did not always work well with people and partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm.

Measures identified by external agencies to improve the safety in the home had not been responded to, however when this was highlighted by the inspection team, the provider and management team were quick to respond and address concerns.

The provider’s policies regarding safeguarding were not current and contained guidance that was no longer in use. The area manager replaced the out-of-date policies during the inspection and put in copies that were current and contained the correct legislation and contact details for external agencies.

There were some restrictive practice measures in place including locked doors, but they were to promote people’s safety and were legally justified, proportionate, necessary and as a last resort.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We observed one person was not provided with the correct level of support to promote their health and protect them from the risk of infection and there was no guidance in the person’s care plan around this. This was discussed with the home manager at the time who addressed this immediately.

Care plans indicated people and those important in their lives were involved in care planning but people and relatives told us they were not consistently involved in planning care and supported to be involved in managing risks or provided with information in a format that would empower them to manage risk.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider and management team had failed to identify a number of concerns in the home including doors that were not fire safe and windows that were not restricted in line with the HSE regulation. These concerns placed people at risk of harm including risk of harm from fire or from falling from height or leaving the home without support. We issued a Letter of Concern to the provider outlining the urgent concerns and a response date for them to advise us of the action they would be taking and when. The provider swiftly addressed these issues to mitigate the risk of harm to people.

The home did not require any special adaptations or reasonable adjustments to meet people’s individual needs.

The provider did not consistently follow a robust recruitment process to ensure the correct people were selected to work at the home. This was discussed with the management team at inspection and actions were taken to address this. However, the provider had checked the criminal record of staff applying for a role. This is known as getting a Disclosure and Barring Service (DBS) check that helps employers decide if a candidate is suitable for a job.

We reviewed the staff training matrix and supervision planner and found staff received effective support and supervision, and training to meet people’s individual needs. One staff member told us about a recent training session and what they had learnt, “[I learnt] how to handle the behaviours, we obviously can’t restrain people, different methods to calm them, different ideas for what to do.” This meant staff had training to support people with more complex care needs for example people living with a learning disability and autistic people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of infection spreading. The provider did not have an effective process to ensure infection prevention and control was managed effectively.

We saw that the home was not always kept hygienically clean and found in one person’s room the curtains were soiled, there was a mildew-stained bathmat, and the chair cushion was malodorous. Bathroom floors were not properly sealed so they could not be effectively cleaned, surfaces were damaged, and light pull cords did not have a plastic coating so could not be kept hygienically cleaned, and bins in use were not foot pedal operated.

The provider was quick to address the concerns highlighted and rectified the issues identified.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning and the policy was out of date.

For people prescribed topical medicines there was no guidance for staff on where to apply the cream and staff failed to record when people were supported with this so there was no assurance that people were receiving the cream as prescribed.

The management team addressed these concerns at the time of the inspection but the improved ways of working need to be embedded.

People who expressed distress or an emotional reaction, only received psychotropic medication as part of treatment that includes psychosocial interventions. The provider was following STOMP - Stopping Over Medication of People with a Learning Disability – principles, but the home manager was not familiar with STOMP which they addressed at the time of inspection.