George Potter 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

People and relatives were encouraged and supported to raise safety concerns with the provider. Managers and staff understood the importance of reporting safety concerns and learning lessons when things went wrong. Systems were in place to support staff to report and record safety concerns and events. Managers investigated safety concerns and events and used the learning from these to support staff to continually improve their practice, reduce risk and keep people safe. Managers told us clinical review meetings took place every 2 weeks and ‘lessons learnt’ workshops were held in response to specific incidents that happen. One of the managers said, “Points for learning are highlighted during handover and supervision, and we have clinical review meetings and lessons learnt workshops where we discuss incidents.”

The service 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.

Information was obtained from people, and others involved in their care, about people’s individual needs and risks they might face. This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care and support from the moment they moved into the care home.

The provider worked with people and external health and social care partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safe, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

We observed a pleasant and relaxed atmosphere in the care home and people looked at ease and comfortable interacting with staff. People told us they felt safe living at this care home. A relative said, “I do think my [family member] and everyone living at George Potter House is safe living there and staff do understand how to keep people safe.”

Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. Managers worked proactively with the relevant external agencies, when a concern was raised, and took appropriate action to safeguard people from further risk, when this was required. One of the managers told us, “We’ve got to be transparent and we raise safeguarding ourselves.” An external social care professional added, “Recognition is given to George Potter House having raised safeguarding alerts themselves when required. This shows us the service now knows what to do and how to raise/report potential safeguarding concerns.”

The service was working within the principles of the Mental Capacity Act 2005 (MCA). Staff understood people’s capacity to make decisions about the care and support they received. Managers and staff had received up to date safeguarding, mental capacity and Deprivation of Liberty Safeguards (DoLs) training.

The provider did not always work well with people to understand, assess and record risk management plans to help staff prevent or manage risks. Staff did provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found no evidence that people had been harmed however, records relating to risk were not always accessible or well-maintained. This meant staff did not always have access to sufficiently detailed and up to date recorded guidance and information for them to follow and ensure they knew what action they needed to take to keep people safe. For example, we found omissions on daily fluid charts for people identified as being at risk of dehydration which staff were expected to keep up to date and accurate. We also found bedrail assessments were not always in place and those that were, sometimes contained out of date and inaccurate information. This contradicted recognised best practice and the provider's own risk assessing and management policies and procedures.

We discussed this issue with the managers at the time of this assessment and they acknowledged how risks people might face were assessed and recorded at the service needed to be improved. One of the managers told us, “We’re in the middle of transitioning from paper records to an electronic care planning system and our staff are still trying to get to grips with the technology, hence these risk recording issues. We will improve through further information technology training and extra support for staff.”

However, staff were aware of the risks people might face and the steps they needed to take to prevent or safely manage them. Staff were attentive and alert to any changes that indicated people needed support for any anxiety or discomfort they might be experiencing.

The service did not always detect and control potential risks in the care environment. We saw the care homes environment was not particularly ‘dementia friendly.’ For example, most communal areas lacked any meaningful easy to understand pictorial signage, colour contrasting bedroom doors or memory boxes near people’s bedroom doors for people living with dementia. The introduction of these visual clues would benefit people living with dementia in the care home as it would help people orientate themselves and identify rooms that were important to them. We discussed this issue with managers at the time of this assessment and they agreed to seek advice and guidance from reputable sources about how to make the care homes environment more ‘dementia friendly’. We will review progress made by the provider to achieve this stated aim at our next assessment. Since our last inspection, most bedrooms and communal areas on the ground floor had been redecorated and refurbished and the rear garden landscaped. The environment was free from unnecessary slip or trip hazards. Fire and health and safety systems and equipment were well-maintained and serviced at regular intervals. For example, the provider had an up-to-date fire risk assessments in place for the building and personal emergency evacuation plans in place for everyone who lived at the care home.

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.

The provider continued to operated safe recruitment practices and only suitable staff were employed to work at the care home.

Managers told us they continued to actively recruit new staff and were no longer reliant on temporary agency staff to cover these workforce pressures. A manager said, “We do have staff vacancies but these are decreasing as we recruit more and more new staff. We do have to rely on agency staff sometimes, especially at night, but we always try and use the same agency staff where possible to ensure the care people receive is consistent.” A relative added, “The care home is mainly staff by long-term permanent staff now, so I don't think they have to rely too much on agency staff anymore.”

Staffing levels in the care home matched the staff duty rotas on the days we visited. Staff were visibly present throughout the assessment and were quick to respond to people’s questions and requests for support. A member of staff told us, “Staffing rotas were planned based on people’s dependency and individual needs.”

Staff were well-trained and supported to meet people’s individual needs, in line with their choices and preferences. A relative said, “Staff are very familiar with my [family member] needs and they seem well-trained.” Staff received e-learning and in-person practical and theoretical training, with regular refreshers and practical competency assessments as needed.

Staff were supported with their learning and development needs and encouraged to continually improve in their role. Staff had ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might 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. People were supported to live in a clean, hygienic environment.

Staff had received relevant infection control and food hygiene training, which meant they knew the processes to follow to minimise the risk and spread of infection. Staff had access to resources and equipment to help them reduce infection risks. People told us staff wore appropriate personal protective equipment [PPE] when they supported them with any personal care and their flats were routinely cleaned by the domestic staff. A relative told us, “Staff wear their PPE when needing to do so, and always meet my [family members] personal care needs. Their bedroom is always kept clean.” The provider’s infection prevention and control policy was current and reflected national guidance.

The provider did not always ensure medicines were safely stored, although they did make sure people received their prescribed medicines as and when they should.

The provider had made improvements to the way they managed medicines since our last inspection. This was because the provider now had up to date and accurate protocols in place for the use of ‘as required’ medicines and daily records of clinical room and fridge temperature checks where medicines were stored.

However, medicines were not always safely stored because staff failed to keep the clinical room and medicine fridge locked when not in use, potentially allowing unauthorised access. Managers and staff responded to our concerns immediately by securing the clinical room and fridge, and properly stored the medicines.

We discussed this issue with managers and staff at the time of this assessment who responded immediately by ensuring the clinical room and fridge were securely locked as soon as the matter was raised with them. Managers will remind staff authorised to handle medicines in the service to ensure clinical rooms and fridges where medicines are stored are always kept securely locked when they are not in use.

Medicines stocks, balances and records showed people consistently received their prescribed medicines as and when they should. People confirmed they received their medicines as they were prescribed.

Care plans included detailed guidance for staff about how people needed and preferred their medicines to be administered. Staff received relevant training and their competency to continue managing medicines safely was routinely assessed. There were regular audits of medicines at the service.