Deer Park 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There were systems in place to report incidents and conduct a post incident review, ensure learning was identified from incidents and shared with staff. Staff recorded any accidents and incidents that occurred, and these were reviewed by senior staff and management to identify any action that could be taken to prevent a similar incident from occurring again. For example, a person had a fall. Management analysed whether there been staff miscommunication by not following proper moving and handling techniques or whether the risk assessment to prevent falls had not been comprehensive. The lesson learnt, involved enhanced staff training, comprehensive risk assessments, use of appropriate equipment, and a post incident review. This was shared with staff through staff meetings and discussions.

Staff 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. People’s needs were assessed before they moved into the service. Staff knew which health and social care professionals were involved in people’s care and were able to explain what type of service they offered. For example, speech and language therapists (SALT) and mental health practitioners. Staff monitored people’s health conditions to ensure timely referrals were made to other services where required. For example, referrals had been made for a care act advocate and for onside advocacy.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. People told us they felt safe living at the home and with the staff who supported them. Staff told us and records confirmed they had received training about how to recognise and report abuse. They felt confident to raise and escalate concerns and the process to follow. One staff member told us, “Any concerns I would raise with management. If management didn’t do anything I would go higher/up the ladder. If still nothing done, I would report to CQC or the local safeguarding authority.” Another staff member said, “I haven't personally had to raise anything. If needed to, I would not hesitate, it’s in the best interest of everyone to raise any concerns.” There was a safeguarding tracker in place which showed safeguarding incidents were reported, recorded and investigated. Referrals had been made in a timely manner, were reported appropriately to the right agencies such as the local authority and CQC and included actions taken and outcome. Where people were being deprived of their liberty, applications had been sent to the local authority for authorisation. There was a tracker in place to monitor and ensure authorisations were current, valid and to take action when they were due to expire.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff knew people well and told us they were provided with enough information to support people. Staff explained what information was accessible to them. This included key information such as risks to individuals and how to support people to manage risks. For example, risks associated with nutrition and hydration, catheterisation, wound management, and percutaneous endoscopic gastrostomy (PEG) management, a procedure which allows nutrition, fluids and/or medications to be put directly into the stomach. People who required support with moving and handing had up to date guidance for staff to follow including any risks related to moving and handling care tasks. Information was available for staff to follow to ensure concerns were reported.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People had access to the equipment they needed to maintain their mobility and safety, including hoists.

We observed safe staff practice when they supported people to mobilise. Regular checks and audits were carried out to ensure the home and equipment used for people’s care was safe. This included health and safety and fire safety checks. Radiator covers and window restrictors were in place. Fire extinguishers were in date. Risk assessments in relation to equipment used in people’s care had been completed to identify any risks and measures put in place to mitigate these. Staff understood how to report any maintenance issues.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People told us there were enough staff available to meet their needs. Two people said they had to wait some time before the call bell was answered. The manager followed up this issue with staff to ensure people received a timely service. We did not hear calls bells ringing for long periods of time and so on the day of the inspection people did not have to wait for care and support when they needed it. Staff told us they felt there were now enough staff on shift to enable them to provide safe care to people. The manager told us they had just recently held a recruitment day and job offers had been made.  We observed staffing arrangements met people’s needs. Staff were recruited safely. Checks were undertaken on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS checks helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Staff had received relevant training to carry out their roles effectively. This included training in areas such as safeguarding, dementia, communication, person centred care, first aid and fire safety. New staff completed an induction. A staff member said, “I completed an induction when I started which included training such as manual handling and shadow shifts with more experienced staff.” Staff told us they had regular supervisions to reflect on their performance and identify support they may need.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We observed the environment was clean, tidy, and to a high standard. This included communal areas and people’s bedrooms. We did not identify any concerns in relation to infection prevention and control (IPC). Staff told us they were provided with appropriate personal protective equipment (PPE). Domestic staff were visible. The kitchen and laundry areas were clean and well organised. Regular IPC audits of the home were carried out and cleaning schedules were in place. For example, daily and weekly checks carried out by domestic staff and monthly audits carried out by the management team. Records confirmed staff had received infection prevention and control training.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were managed by staff who had received the relevant training and regularly had their competency assessed. Appropriate management systems were in place to ensure medicines were managed safely. Electronic medicine administration records contained sufficient information, such as allergies of each person to ensure safe administration of their medicines. There was clear guidance in place for ‘as and when required’ (PRN) medicines for staff to follow. Where a person received their medicines covertly, there were assessments in place to ensure this was completed safely and in peoples' best interest. This was recorded in care plans for medicines management and clearly documented in the MAR chart documentation. People who required medicines to be administered with food or drink had guidance in place for staff to follow to ensure this was completed safely. Controlled drugs were in a locked cupboard in a locked clinical room. Records required to maintain controlled drugs were up to date and clearly recorded. There was evidence of stock checks twice a day. We did identify some prescribed topical medicines did not have a clear label of the person and had not been dated when opened. This was reported to the manager who told us medicines were monitored and reviewed prior to administration, to follow the manufacturers recommended expiry date. We observed this was the case during medicine rounds. Medicines storage areas were at acceptable temperatures and the frequency of temperature was monitored and recorded daily. Records of the medicines requiring refrigeration were stored at correct temperatures. Waste medicines were disposed in a large secure container and stored in the locked clinical room. There were clear records, and a contracted company regularly removed clinical waste.