Creedy 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

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care, which meant the legal requirement for safe care and treatment had not been met. Lessons were learned when things went wrong, however actions to embed the lessons learned were not always robust. Some staff had not completed all the relevant training to be able to meet people’s needs safely, this evidenced the legal requirement for staffing had not been met. 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. There was a plan in place to make sure staff had ongoing support in the form of supervision and appraisal meetings. Staff were recruited safely. There were enough staff to support people safely. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes to health and identify care and support needs. Accidents and incidents were reviewed and actioned by the management team, safety checks undertaken by staff. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection. We observed some infection control issues during the assessment, however these were dealt with. We were assured that the provider was working to improve safety through the layout and hygiene practices of the premises.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could not be assured that people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. This is because there was no record of the analysis and actions. Relatives told us they were kept well informed when there were incidents, changes or concerns. A relative said, “They will normally tell me anything that has happened. They phoned me [when there was an incident between another person and mum], reported it and put the gate up straight away.”

The registered manager told us lessons learned were identified during investigations. Verbal and written feedback to the teams was at meetings, during handovers and the management team had carried out unannounced spot checks to ensure staff were working safely. Staff told us they felt confident to report any incidents or raise concerns and were confident that the appropriate actions would be taken. Staff were fully aware of the accident and incident reporting procedure and records confirmed that staff documented these appropriately. A staff member said, “Changes from accidents have been made, for example, one person fell from their bed; their bed was already on the lowest setting and there was a crash mat in place which alerted us. However, they climbed over the bed rail, so [they] now has an extended bed rail which keeps [them] from falling, making [them] safer, and [their] care plan has also been updated.”

Accidents and incidents were recorded and the information was analysed so that trends and patterns could be identified, and appropriate actions taken. However, it was not always clear that learning from accidents and incidents had been embedded as the analysis had not identified areas of concern which included lack of training and times of incidents. For example, a number of accidents and incidents happened in the evening. We discussed this with the registered manager to check if the staffing levels had been reviewed at this time of day. The staffing levels had not been considered. Safety checks undertaken by staff including maintenance, were audited and checked by the management team.

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 felt safe and protected from harm. A person gave us an example of incidents that had occurred. They said, “I was on the ground floor when I came here, but this resident used to come into my room. They fitted a gate in my door, but it made no difference. Then they moved me up here and I feel a lot safer. No one barges in. There are security doors as well.” Another person said, “Oh yes, I feel safe.” Relatives told us that people were safe. Relatives told us they were confident to raise any concerns and knew that they would be responded to.

Staff had received adult safeguarding training. A staff member said, “I would reassure the resident, listen to them and then call the nurse. It would be dealt with and I could report to the manager.” Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member said, “I would report safeguarding to the manager and it would be dealt with. I could report to KCC, the police or CQC.” Another staff member told us, “I could whistle blow and I could report to the local authority or CQC. There is a notice with contact details.”

We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Most people required physical support to move around the service. Stairs were gated and the lift and doors were accessible by keypads to safeguard people from harm.

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Safeguarding policies did not include information about safeguarding children from abuse. Safeguarding training did not include safeguarding children. Staff in care services should receive safeguarding children training as they come into contact with children as part of their work. This meant that staff did not have all the information they needed to work safely. Safeguarding concerns had been reported appropriately. The management team told us they had positive working relationships with the local authority and were confident to seek advice and report safeguarding issues in a timely way. The management team had reviewed processes and learnt lessons from safeguarding incidents. We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty. The service worked within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. When people were assessed as lacking capacity to make decisions appropriate procedures were followed to ensure principles within the MCA were followed. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place.

People and relatives gave us positive views about how staff managed risks. A relative told us, “They spoke to me about what [person] needs and most importantly they involved [person]. If there are any changes, they will call me and will not do anything until I agree. They are very diligent. The night nurse noticed [person] had a swelling on his elbow at 06:00. They didn't wait but called out of hours and got antibiotics immediately.” Another person’s relative told us that their loved one was safe from harm because staff used equipment to move them.

Some staff knew people well. Not all staff were aware of people’s risks and how to keep safe. Staff told us that this information was not included in people’s care plans and risk assessments. A staff member said, “The information about what to do (about a diabetic hypoglycaemic attack) is not in the care plan, we just have to inform the nurses. I was always taught if there is a diagnosed need there should be a care plan for it, this doesn’t happen here.” Another member of staff said, “Everyone with epilepsy would have a risk assessment.” The registered manager was not aware that risk assessments and care plans were not in place until we raised it. They arranged for these to be completed after we raised it. Kitchen staff had a good understanding of people’s diet and different textures that they needed to ensure they could eat safely.

We observed that risks were not always well managed. We observed a person being supported to eat their meal by a member of staff in an unsafe position which compromised the person’s safety. We spoke with the staff member and reported the incident to the registered manager. The registered manager ensured that risk the person's risk assessment was updated and staff were spoken with about safe working practice. People were supported to move around the service safely and were supported to spend time where they chose. Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. Some PEEPs were not detailed enough to detail what emergency evacuation equipment was required to support them to evacuate in the case of an emergency.

Risks to people were not always identified and risk assessments lacked enough detailed information for staff to know how to keep people safe. For example, moving and handling risk assessments for people who required the use of hoists and slings were not clear about the sling type, size and which loops to use on the sling when transferring people, this put people at risk of harm. People with diagnosed health conditions had no risk assessments or care plans in place to give staff information and provide care staff with safe ways of working with them. For example, a person who lived with diabetes and was prescribed insulin did not have a risk assessment in place or a care plan. We observed several times during the day where people were in their bedrooms in their beds without equipment in place which they had been assessed as requiring. Crash mats had been identified for 2 different people as equipment to prevent them from hurting themselves if they fell from their beds. We observed these people in bed without care staff present and without the crash mats in place. A person with a percutaneous endoscopic gastrostomy (PEG) which is a surgically fitted feeding tube had their medicines and food through their tube following specific guidance provided by a specialist team. The patient information leaflet for 1 of the medicines they were prescribed detailed their medicine was not suitable to be crushed, they were prescribed the medicine in tablet form and not in liquid form. Nursing staff had not identified this and reported the concern to the GP and pharmacy. This put the person at risk of their medicine not working effectively. Risks of constipation were not always managed well because care plans and risk assessments did not detail what staff needed to do if the person had not opened their bowels for a period of days. As and when required medicine (PRN) protocols also did not detail at what point medicines should be given and when further escalation to a GP was required.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People gave us mixed views about whether there were enough staff on duty at the service. Comments included, “I have a buzzer here and I do use it. They come promptly, well as quick as they can” and “I have a buzzer here which I use. They come as quickly as they can. It's ok, I understand that they are busy people.” A relative told us sometimes there were not enough staff around. They gave examples of visiting at weekends and not being able to find staff to support with personal care tasks for their loved one. Other relative said, “I think so (in answer to if there were enough staff) I think they do a good job” and “There seems to be enough. I suppose she is able to call if she needs something.” A regular visitor told us, “There always seems to be enough staff around.”

Staff gave us mixed feedback about whether there were enough staff on duty with the right training to provide safe care. Staff working in the Lodge and The House had different experiences. A staff member said, “There are not enough staff on shift to meet people’s needs. We are still finishing morning washes at lunchtime and that’s with rushing. There’s 1 staff in the house who is always in the lounge which leaves 6 staff to do all the personal care and support with breakfasts, drinks etc. People are often only just getting up at lunchtime and that’s not their choice. We don’t have time to sit and chat with people, we can only do this when washing them.” Another staff member told us, “There is enough staff. There is always 1 carer in the lounge at all times due to risks of people getting up and walking or incidents [occurring] between people. Staff are divided by the Lodge and main house. There are 4 in the lodge and 7 in the house. We have enough time to provide care and people are not rushed.” Staff told us that new training courses had been added to their training requirements following our visit. A staff member said, “I had done all my online training but they added lots more courses yesterday. I had completed all the mandatory courses and I had done diabetes when I did my level 3 [qualification]. But it has just been added again as it was out of date. I have done safeguarding vulnerable adults and children’s safeguarding was added yesterday.” A staff member told us they did not know what epilepsy was. Another staff member said, “I would call emergency buzzer if someone had a seizure and the nurses would take over.” Another staff member said, “We have supervision chats with the nurse every 2 months and we can discuss things and talk about things including training. It is a free space to talk and is very, very inclusive.” Some staff received frequent supervision, some staff reported this was not so frequent.

We observed there were enough staff on duty to support people. Call bells were answered quickly. Staff were interacting politely with people; however some staff did not always listen to people and interact respectfully. For example, we observed a staff member offering people hot drinks. They asked a person who was very clear they did not want one. They were shaking their head, saying no and I don’t want it. The staff member made them a drink anyway and placed it in front of them. This caused the person to become more vocally agitated and anxious. This had a knock-on effect as this then distressed other people in the room.

Staff had not always received all the training required to meet people’s assessed needs. Training records showed only 8 staff in total had done epilepsy training (2 of these were non care staff), 4 care staff had not completed learning disability training (despite people with learning disabilities living at the service). Only 10 staff had completed oral health training, 5 out of 8 nursing staff had done skin integrity training. Kitchen staff had not completed diabetes training. Staff were carrying out risk assessments without the training and knowledge to do so. The registered manager told us this had impacted a person at the service who suffered injuries as as result of an inappropriate bed. Only half of the nurses had completed catheter care training. We raised this with the registered manager and courses were added to staff training accounts for completion and external courses were sourced. Staff had supervision meetings and induction was a mixture of training and shadowing experienced staff to gain confidence and experience. Staff had been safely recruited. We examined 4 staff files, all of the required checks had been carried out and documents were all in date. In files we saw copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council and the provider had made checks on their personal identification number, their registration status and their renewal date. There were enough staff deployed on shift during the assessment to meet people’s needs and provide safe care. The service used a dependency tool, this had been updated regularly, which helped the manager to calculate the number of staff needed.

Staff told us they had sufficient equipment and PPE (Personal protective equipment) to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member said, “PPE is stored in each person’s bedroom and in bathrooms, aprons are in drawers.” Another staff member told us, “We use yellow bags for clinical waste. If an infection occurs we set up a PPE station outside the room and put a sign on the door and strict instructions.”

We observed that some areas of the service required additional cleaning, which was an area for improvement. We saw dried faeces on the floor of a person who was cared for in bed. This had been stood in and walked along the corridor. Staff had not noticed this had happened and had not cleared it up, which increased the risk of infection. Records showed the person had been supported with their continence care 3 hours prior to us observing the issue. We also observed a bathroom which had overflowing waste bins and a seat which required replacing due to infection risks. We reported these issues to the registered manager who arranged for the housekeeping staff to clean the area. The maintenance team replaced the seat when we were onsite. The provider was promoting safety through the layout and hygiene practices in the rest of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment. We observed that the staff were using PPE effectively and safely.

People told us their bedrooms and the service were clean and tidy. People were supported to change their clothing if they had spilled food or drink down themselves. A person said, “My room is very clean. They come in each day.” The provider had systems and processes in place to assess and manage the risk of infection. They were able to detect and control the risk of it spreading and share any concerns with appropriate agencies promptly. The provider had a daily cleaning program in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms. The provider had plenty of PPE in place to keep people and staff safe. The kitchen areas were clean and well managed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.