Cann House Care Home

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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

This key question has been rated requires improvement. We identified 2 breaches of regulation in respect of safe care and treatment, and good governance systems and processes. The providers governance systems and processes had failed to identify people were not always protected from the risks associated with the environment they lived in and people’s rights were not always protected. Risks associated with people’s skin were not being fully managed and mitigated. Care plans and risk assessments were not always up to date or contained enough information to guide staff on how to care for people safely. Improvements were needed to ensure all medicines were managed in a safe way.

Staff understood how to keep people safe and their responsibilities in relation to reporting accidents, incidents or concerns. Systems and processes were in place to ensure there was continuity of care for people moving between healthcare services and providers. The service was clean and free from the risk of infections.

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.

Staff understood how to keep people safe and their responsibilities in relation to reporting accidents, incidents or concerns. People were supported to take risks to retain their independence whilst any known hazards were minimised to prevent harm. People involved in accidents and incidents were supported to stay safe and action had been taken to prevent further injury or harm. Where people had accidents or incidents these were recorded and monitored to look for developing trends and themes. Relatives and health care professionals were kept informed of accidents and incidents and relatives told us communication from the service was good. One relative told us, “I’m comfortable with falls management. All staff are quite well trained. They let me know in a timely way.”

Systems and processes were in place to ensure there was continuity of care for people moving between healthcare services and providers. This included staff carrying out assessments of people’s needs prior to them moving into the service to ensure they could meet their needs, and any equipment needed would be put in place. A health professional told us, “We have always found them to be very responsive. They work closely with us to ensure that they have the most up to date information and the correct equipment prior to admission.”

When people needed to go into hospital, information about them and their care needs was available and sent with the person to ensure they received safe care.

The providers governance systems and processes had failed to identify that people’s rights were not always protected and staff had not acted in accordance with the Mental Capacity Act 2005. The registered manager had identified people who they believed were being deprived of their liberty. They had made Deprivation of Liberty Safeguard applications to the supervisory body. However, people’s mental capacity had not always been assessed and decisions which had been made in people’s best interests, were not documented. This contributed to the breach of regulation in respect of good governance.

People told us they felt safe living at the service. Comments included, “They look after me well, I feel safe” and “Yes, the staff check on me regularly.” Staff were trained and understood their responsibilities to keep people safe. One staff member told us what they would do if they suspected a person was at risk of abuse or neglect, “I would speak to my manager if I did want to whistle blow as first point of contact. There is info in our staff room with all the contact numbers there.” The service had policies and procedures in place to record and investigate potential abuse. We saw that appropriate action had been taken where abuse had been reported.

People were not always protected from the risk of harm. Risks associated with people’s skin were not being fully managed and mitigated. For example, where people had been assessed as having vulnerable skin and required staff to help them change their position, we found repositioning regimes were not always being followed according to people’s assessed need. Pressure relieving mattresses and equipment were in place, however, we found this equipment was not being checked daily to ensure they were set on the correct setting according to people’s weight. Care plans and risk assessments in place did not always contain enough information to guide staff. For example, one person’s care plan did not guide staff on the level of thickened fluids they needed, nor did it say what assistance the person needed with their meal. This placed this person at risk of choking. Care plans were not always up to date, this meant that people may not be receiving the correct care and treatment or may be receiving treatment that was not necessary.

Systems and processes were in place to check that people were receiving the care they needed, and care plans contained enough information and were reflective of people’s needs. However, these were not robust or effective and had not identified the concerns we found.

This contributed to the breach of regulations in respect of safe care and treatment.

People described what staff did to support them to manage risks associated with their care needs. For example, people told us about how staff supported them to maintain healthy skin and to move safely. One person said, “They look after my skin with creams and soaps and constantly check tissue viability. I'm checked every day, and any issues raised go to the nurse.”

People and their relatives did not express any concerns about the safety of the environment. However, whilst people and relatives did not highlight any concerns, we found that people were not always safe from risks associated with their environment. During our site visit, we observed that not all windows in the service had been fitted with suitably robust tamper-proof restrictors to ensure compliance with health and safety legislation. This exposed people using the service to the risk of falling from a height. We also found radiators throughout the service did not have radiator covers fitted in line with health and safety legislation. This placed people at risk from burn injuries. People were not always protected from the risk of fire. Fire safety checks had not all been completed. For example, fire extinguisher checks and checks of emergency lighting had not been completed since July 2024 and fire drills had not taken place since 2023.

The providers governance systems and processes in place to ensure people were protected from risks associated with their environment had failed to identify the concerns we found.

This contributed to the breach of regulations in relation to good governance.

We received mixed feedback about staffing at the service. Most people and their relatives felt there were not enough staff, staff were always busy and did not have much time to spend with people. One person told us, “They (staff) are very busy, and they don’t have time to talk. They’ll ask how I am but can’t stop.” However, others felt that people did not have to wait long for care. One relative told us, “Yes. Sufficient staff. (Name) is never left on their own for hours. They act as quickly as they can when asked.” We observed there appeared to be enough staff but did note that call bells were constantly ringing which would suggest people were having to wait for their care needs to be met. We spoke with the registered manager about this. They told us they did not use a dependency tool to assess how many staff they needed to support people. They acknowledged there were busy times of the day when call bells were ringing for longer but told us they monitored this and took action if they thought more staff was needed.

Staff told us they received supervisions with their line managers, but this was not consistent. We found there were no formal process in place to record that staff had received supervisions. This meant that opportunities for staff to discuss their roles, performance and training needs may be missed or delayed.

People were protected from being cared for by unsuitable staff because the provider had safe recruitment processes in place. New staff completed an induction, and a training programme was in place to ensure staff had the skills necessary to care for people.

People and their relatives told us the service was clean, and staff wore PPE when supporting them. One relative told us, “The home is clean and well kept. Surprisingly so. Just like a hotel. No smells.” Another relative said, “The home is spotlessly clean. The room is beautiful.”

People were protected from the risk from infections and cross-contamination. Staff had access to PPE (personal protective equipment) and we observed staff using this safely. Systems were in place to ensure the service was clean and free from infections and audits and checks were in place to highlight any issues of concern.

Improvements were needed to ensure all medicines were managed in a safe way. Where people were being supported by staff to manage their diabetes, we found there was a lack of guidance for staff, which put people at risk of harm. For example, we found there were no protocols or guidance in place to guide staff about what range a person’s blood glucose levels should be and what to do if the person’s blood glucose level went outside of this range. A lack of clear guidance in place put people being supported with their diabetes at risk and contributed to the breach in relation to safe care and treatment.

People told us staff managed their medicines well and they received them when they needed them. One person said, “I’m on loads of medication. They give it to me in a little white cup and watch me take them.”