Cantley 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 changed to requires improvement. 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.

The provider was in breach of legal regulation in relation to the management of risks.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The provider did not have a system in place to evidence lessons were learnt from incidents. We discussed this with the registered manager, who explained there were no incident or events that had occurred which could be used as learning. There were some missed opportunities to learn and improve the service.

The provider 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 had hospital passports which accompanied them in the event of hospital admission. These documents gave important information about people so that care and support could be seamless. People had access to healthcare professionals as required.

The provider worked with people and healthcare 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 safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. The registered manager knew the safeguarding process and said they would take appropriate action to keep people safe. There was a record sheet in place to record any safeguarding concerns and there outcome. The registered manager told us they had never had cause to raise a safeguarding concern regarding the home.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe. One person accessed the community independently but did not have a clear risk assessment detailing what action staff should take if the person did not return home. Following our site visit, the provider updated the risk assessment to ensure the person was empowered to take risks but had a clear procedure in place to ensure their safety.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities, supported the delivery of safe care. During our site visit we identified windows had no window restrictors in place, radiators were very hot to touch, and some fire doors were wedged open. We completed a second site visit and found some window restrictors had been fitted, however, 1 window restrictor was still required in the main bathroom situated on the first floor. Also, on our second site visit we found some radiators were still very hot to touch. We asked the provider to take action to reduce the risk of harm to people and were sent confirmation that the window restrictor had been fitted, and radiator covers had been ordered.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff received training in mandatory subjects but had not completed any training specific to supporting people with a learning disability. The provider had identified this and assured us this would take place. We looked at staff recruitment files and found staff had been recruited safely. Staff told us they felt supported and worked as a team.

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. The home was clean and tidy and reflected the preferences of people living there. The provider had recently replaced some flooring in the toilet to ensure this was easy to clean. Staff received training in infection, prevention and control and understood the importance of keeping the home clean. Night staff had a cleaning schedule in place to ensure cleaning continued throughout the night.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people were prescribed medicines on an ‘as and when’ required basis, often known as PRN. Protocols in place to ensure these medicines were managed safely, did not always contain sufficient detail. For example, there was no information about how people may present if their medicines were required. We carried out a sample check of medicine stock and found some anomalies. The registered manager informed us they would take action to resolve this. Some handwritten entries on medication administration records sheet were not double signed.