Netherclay 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 inspection 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 regulations in relation to risk management and staffing. People did not receive consistent, prompt support from staff to manage risks associated with their health and wellbeing. For example, where people were at risk of pressure damage to their skin, robust repositioning was not being actioned and guidance from health care professionals was not being followed. The provider had failed to ensure there were enough staff to keep people safe from avoidable harm. Staff told us there were not enough staff to meet people’s needs and respond to call bells as they were busy supporting people. People lived in a safe and well-maintained environment.

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

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.

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

People did not receive consistent, prompt support from staff to manage risks associated with their health and wellbeing. People’s personal risk assessments relating to the health, safety and welfare were not always completed promptly. This meant care plans were not always put in place to support people to manage risks. For example, where people were at risk of pressure damage to their skin, robust repositioning was not being actioned and guidance from health care professionals was not being followed. Also, where a person was at risk of dehydration, staff had not followed the GP guidance to ensure they had adequate fluids. Monitoring charts, including repositioning and fluids were not being fully completed and staff did not understand the importance of this monitoring. In the past 3 months there had been a high number of unwitnessed falls at the home. A lot of people had been assessed as requiring pressure mats to alert staff through the call bell system if people were walking unaided. Call bell response times were not monitored to ensure staff responded quickly when call bells were sounded. This posed a risk to people as staff may not respond promptly and fail to reduce the risk of falls.

People lived in a safe and well-maintained environment. Regular health and safety checks were conducted at the home. Actions were reported and resolved promptly where this posed a health and safety risk.

The provider had failed to ensure there were enough staff to keep people safe from avoidable harm. Staff said there were not enough staff to meet people’s needs and respond to call bells as they were busy supporting people. They said they didn’t have time to read people’s care plan information in full, to help them understand how best to support people to stay safe. The registered manager told us on the first day of our visit that they had identified a high number of falls, particularly in the evenings in the past 3 months and felt a ‘twilight shift’ was needed ideally between 7pm and 10pm. When we returned, 9 days later this had not been put in place. Therefore, the risk of falls had not been reduced. This was put in place the same day. The service had a dependency tool in place to analyse the needs of people in the service. However, this information was not used to increase staffing levels when people’s needs had changed and more staff had therefore been required. Healthcare professionals raised concerns about some people at the service having more significant cognitive difficulties with additional support needs. Concerns were raised about the high level of falls at the home and the additional external clinical input required due to people’s increased healthcare needs. In response to our feedback, the providers increased the staffing levels at the home, initially for 2 weeks and would then review people’s needs again. The providers told us they would approach the commissioners to request an assessment of people with high needs to ensure they were in the appropriate service. The provider followed safe recruitment practices and appropriate pre-employment checks were completed. The registered manager put in place a formal induction process for agency staff during the assessment process. Staff had received training and further training was being delivered to improve staff skills in meeting people’s care needs. For example, in falls management and tissue viability.

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

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