Figham 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 the same.This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have proactive and positive culture of safety, based on openness and honesty. They did not always listen to concerns about safety. Lessons were not always learnt to continually identify and embed good practice. During the inspection visit some staff members were observed undertaking poor practice. This had not been identified or raised by other members of the staff team. Accidents and incidents were recorded, investigated and tracked. The registered manager undertook regular analysis of these to prevent recurrence. Information from these was shared with staff. However, outcomes and recommendations from quality audits had failed to be implemented, nor had lessons been learnt.

Generic risk assessments meant care records did not always reflect the level of appropriate care required. The service worked with healthcare partners to establish safe systems of care. However, these were not always reviewed appropriately. They made sure there was continuity of care, including when people moved between different services. People were admitted to the service safely through thorough assessment processes. Hospital passports were in place to ensure people enjoyed a smooth transition if admitted and discharged from hospital. Handover systems were in place.

Staff had not identified, recorded or raised poor practice observed during our inspection visit. This meant we could not be assured staff recognised all the signs of abuse. Staff had received training about safeguarding. Appropriate systems were in place for recording concerns, when they had been raised, and for tracking and managing these. People told us they felt safe. Comments included, “I feel safe here, there is always somebody around. If I don’t feel safe, I press the buzzer and they (staff) come” and “I am safe here, they (staff) are doing what I need.”

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People nor their relatives were involved in managing risks. Generic risk assessments were often used, for example, for bathing, showering and shaving. These did not consider the risks to individuals. Where people’s needs had changed risk assessments were not always adequately reviewed. For example, one person had suffered fractures and there was no evidence of any risk assessments associated with these. Risk assessments were not always reviewed regularly. This meant people were placed at risk of harm.

The service did not always detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. During our inspection visit the sluice room door was unlocked, and some equipment was incorrectly stored. This meant people were placed at risk, particularly those who live with dementia, who may have gained access to dangerous substances. Appropriate checks and maintenance on premises and equipment took place. Regular audits were carried out and the registered manager undertook a walk round to review the environment and care delivery.

The service did not always make sure staff were qualified, skilled and experienced. The service made sure there were enough staff, who received support, supervision and development. This was not always effective and did not always provide safe care that met people’s needs.  During our inspection visit we observed care that was rushed and task focused during some parts of the day. This meant staff did not always deliver person-centred care or respect people’s wishes. One person told us, “I think sometimes they (staff) can be a bit pushed.” Another said, “Sometimes there is not enough staff, you have to wait a little.” Staff told us there was enough staff. Staff received training and regular supervisions and support. People’s dependency needs were regularly reviewed and used to inform staffing levels. Most people told us staff were responsive to their needs.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The service had not taken actions on recommendations made by the IPC team following an audit visit. For example, all bathrooms were designated as staff ‘donning’ and / or ‘doffing’ stations, and bathrooms were used as storage areas for equipment. This meant there was a risk of cross-contamination in these areas. Thorough scheduled cleaning of the home and equipment took place. Staff wore appropriate personal protective equipment (PPE).

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The service involved people in planning their medicines, including when changes happened. Thickeners used to thicken fluids for people with swallowing problems were not recorded when they had been used. Some medicines, with additional safety requirements, had not been properly identified and risk assessed. Instructions for medicines which should be given at specific times were not always available. The service had systems in place to safely store, administer and record the use of medicines. However, these were not always followed.