Salt Hill Care Centre

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 requires improvement. At this assessment the rating has remained 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.

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 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. Action was taken to understand why a person had become distressed or why an incident occurred and what could be changed to prevent further occurrences. For example, all incidents and accidents that had occurred at the service identified how to mitigate the risk of recurrence, and recorded any lessons learned. The manager told us how they oversaw and monitored the service and any events at the service to ensure safety was a top priority that involved everyone, including the whole staff team, people and relatives.

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. The service was in regular contact with multiple professionals including the care home support team to help ensure people received the required care. Prior to people arriving at the service, the management team conducted assessments to help ensure they were able to meet the needs of the person and support a smooth transition to the service. The registered manager explained how they worked together with professionals and others, through a collaborative, joined-up approach, to ensure safety and continuity of care was a priority throughout people’s care journey. For example, if the service was preparing for a potential admission, the manager worked together with people, their families, and professionals to gather and create plans of care so they could receive the care and support they needed.

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. Where safeguarding incidents had been identified, the registered manager had investigated the incident internally and documented actions taken. Staff were able to explain the process they would take to raise a safeguarding concern. One staff member stated, "I would report to [Registered manager]. I am aware that I can contact the local authority and CQC [Care Quality Commission]." There were systems in place to guide staff on what action to take if they thought a person was at risk of harm. All staff had received safeguarding training and this was up to date. People and their representatives were involved in all aspects of their care. The staff and leaders had taken active steps to ensure there was an open culture. There was evidence that concerns could be raised safely and poor or unsafe practices were identified and challenged. People told us they felt safe living at the service and felt they could raise concerns if they needed to, ““I feel safe because of the attention of the staff and people” and, “I think they listen if I raise a concern.”

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. People were supported and empowered to take risks in areas they wanted to and to enhance their lives. For example, one person was able to leave and enter the home freely in order to take part in activities they enjoy. When people’s needs changed or staff picked up changes in people’s mood or communication style, care plans and risk assessments were reviewed.

Risks were assessed and mitigation put in place to minimise risks where possible. People had risk assessments in place for all key aspects of their care. An electronic care planning system was in place to ensure risk assessments were able to be updated promptly and as required. The management team felt this would help them manage risks to people in the future.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, the provider processes include a monthly check of hoists and slings. There was no evidence of sling and hoist checks, or monthly wheelchair checks since September 2024. There was no record of sentinel temperatures for 6 months and a legionella risk assessment completed on 24 January 2024 identified the service at medium to high risk. We requested evidence of the remedial work being completed as required however this was not received. This therefore puts people at risk of illness if the work was not completed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. People told us they were happy with the staff who supported them. One person said, “The minute they’re with you, they’re very good.” Although the provider completed a dependency tool to identify the number of staff required each day, both staff and people told us at times, more staff were required. One person told us, “Most of the time (staff attend when needed) but sometimes when you urgently need them, they’re not quite quick enough…twice today I’ve had a problem.” Another person required support with their personal care. They required the support from 3-4 staff. The person was waiting more than 1 hour before they were able to get enough staff to help them. The person told us, “Sometimes it may take more than 30 minutes waiting for staff to help me. Staff always respond quickly to call bells but because there is not enough staff, they will just explain they will need to wait until they are able to get more hands to support them.” Another person told us, “Sometimes when you urgently need them, they’re not quite quick enough.” This meant people were not always receiving care in a timely manner. One staff member who had recently started at the service was working on a sponsorship licence from another service. They were not working within the requirements of the sponsorship documentation. This was raised to the provider who stopped their working immediately however this had not been identified by themselves during audits.



One staff member told us, “On our floor we have enough staff. Upstairs I think we need more staff. The carers do say sometimes we need more staff as there are lots of people that need double ups. If both carers are in the room and the nurse is busy, there is no-one in the living room to watch the other residents. I know we do not have enough nurses here.” This was raised with the registered manager who agreed the dependency tool would be reviewed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. During the inspection, we found staining on a bathroom floor, chairs in people’s rooms and in the living rooms were dirty and people’s pillows were stained. This was raised to the provider and although a regular review of people’s communal and private living areas were reviewed on a daily basis, the findings had not been identified. This increased the risk of infection to people. Following the inspection, the provider evidenced arrangements had been made for the areas to be cleaned and flooring replaced.Following the inspection, the provider evidenced arrangements had been made and completed for the areas to be cleaned and flooring replaced.

The service did not always make sure that medicines were stored and managed safely, in accordance with prescriber instructions and best practice guidelines to make sure that people who used the service were not placed at risk. We found medicines that had been given had not always been recorded accurately. When this was raised to the provider, they took immediate action to resolve issues found by inspectors. All staff had received medicines competencies on a regular basis and their medicines training was up to date.