Delves Court Care Home

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were learnt to continually identify and embed good practice. The registered manager spoke confidently about the changes that had been made since the previous inspection to improve the learning culture of the home. They gave us examples of how incidents, accidents and safeguarding concerns were reviewed to ensure lessons were learnt. They demonstrated how they used feedback from people to implement positive changes and told us how they shared this information with staff, who told us they felt involved with this process. There were systems in place to ensure lessons were learnt to ensure good practice was continued.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There were systems in place to ensure people’s needs were assessed before they started using the service. People had care plans and risk assessments which were based on these assessed needs that were continually reviewed and updated when needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately. People felt safe. One person told us, “I feel safe here. The staff know what they are doing.” There were systems in place to ensure safeguarding concerns were identified, reviewed and investigated. Staff told us they had received training and were able to tell us the action they would take if they were concerned. One staff member said, “I would contact the local authority if needed, however I would go to the manager first as I am sure they would act.” When needed, Deprivation of Liberty Safeguards (DoLS) were in place for people.

The provider did not always work well with people to understand and manage risks. Some of the care plans in place lacked detail or guidance. For example, for 1 person with a health condition there was no care plan in place for this. However, other people with the same condition did have detailed plans in place. Another person used a medical device, and this was mentioned in their care plan, however there was no specific detailed guidance around this. Despite this, staff we spoke with demonstrated they knew people’s individual needs, risks and the support they needed. When care plans and risk assessments were in place these were regularly reviewed when needed and when changes occurred. People were happy with how their risks were managed. One person said, “I’d rather be at home, but I’m safer here. If I have a fall or anything the staff are here to help me.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People were happy with their environment, and we saw it was safe. There were processes in place to ensure any potential concerns or risks were identified so that appropriate action could be taken.

The provider had systems in place to ensure there were enough staff available to support people. However, we could not be assured these systems were always effective as some people who used the service reported delays in receiving care and support. We received mixed views on staffing levels within the home. One person told us, “I don’t think there’s enough staff at all. Sometimes when you press the buzzer you have to wait for what sometimes feels like an hour, especially at night.” Another person said, “I sometimes have to wait a long time. They are so busy; I feel sorry for them really. They are too busy all of the time”. Other people raised no concerns and comments included, “I’ve got my buzzer if I want something. They answer it quickly, usually”. A relative commented, “There is always enough staff especially on this floor as it’s nursing patients”. However, during our site visit we saw there were enough staff available for people and they did not have to wait for support. The provider had implemented a dependency tool on each floor to work out the number of staff needed, and we saw staff were available in line with this. Staff told us and records confirmed staff had received training. This included mandatory training and training that was specific to people’s individual needs. We reviewed the training matrix, and this confirmed staff training was mostly up to date. Staff had received the relevant pre-employment checks before they could start working in the home to ensure they were safe to do so.

The provider assessed and managed the risk of infection. People were happy with the cleanliness of the home. One person said, “They clean my room. They are good like that. Cleanliness is important to them.” We saw the home was clean and people were protected from the risk of cross infection. Staff told us they had received training and there was enough Personal Protective Equipment (PPE) available for them to use. People also confirmed this to us. There were processes in place to ensure concerns with IPC were identified so that appropriate action could be taken.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were happy with how they received their medicines. One person told us, “They always give me my tablets. They always check I’ve taken them. I don’t miss them. I always have them.” We saw medicines were stored safely. When people had ‘as required’ medicines there was guidance in place for staff to follow. Staff administering medicines had received training and their competency was checked to ensure they were safe to administer these to people.