Coundon Manor 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. This is the first assessment of this service under this new provider. This key question has been rated 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. Accidents and incidents were recorded and reviewed by managers and senior staff to ensure referrals to other healthcare professionals had been made and action taken to mitigate future risks. Staff were positive about shared learning to mitigate risks and improve their practice. One staff member told us, “If something happens then we must fill in a form with the nurse. We talk about things with the nurse and then we have a meeting. That way we know if we can do it better.” Another staff member commented, “What is important is understanding what happened and knowing what to do to stop it happening again to protect the resident.” The registered manager understood their responsibilities under duty of candour, to be open and honest with people when mistakes had been made.

The provider made sure there was continuity of care, including when people moved between different services. Whilst the electronic care planning system had capacity to produce a hospital pack, some staff still shared information in a paper format. Despite this inconsistency, staff ensured other healthcare professionals had information about people’s immediate risks to their health when they were admitted to hospital in an emergency. A member of the management team told us, “I would say it is not embedded, staff send the information, but it is not consistent with how they send that information." Processes were in place to record people’s medical appointments and ensure transport and staff support was arranged in good time. A member of the management team told us, “We have done a piece of work with the nurses where appointments are booked into the diary and a week before we check if we need to arrange transport."

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. People did not raise any concerns about their safety at Coundon Manor. One person told us, “I think I’m safe, there’s nothing here that makes me unsafe.” Another person said, “I am safe here and feel happy with my care and support.” Staff had received training in how to safeguard people and understood what abuse was. There was accessible information to remind staff of their safeguarding responsibilities and signposting them to the local authority contact numbers. Staff told us they would not hesitate to report any concerns and felt confident to do so. One staff member told us, “The resident could be abused physically, emotionally or it could be something else like taking money. I know if I suspect anything at all, I must go straight to the manager. If they aren’t here, then I go to a nurse and tell them.” Another staff member commented, “[Registered manager] would take action on any concerns. I know she would, but I would go higher if she didn’t.” The registered manager had raised safeguarding concerns in accordance with their statutory responsibilities. When someone was identified as potentially being deprived of their liberty, applications were made to the authorising body as required. Where people had conditions on their DOLs, there was a process in place to ensure the conditions were met.

The provider worked with people to understand and manage risks and staff provided care to meet people’s needs that was safe and supportive. Staff used assessment tools to identify risks associated with people’s health and wellbeing and care plans informed staff how to manage those risks. These included risk reduction plans for clinical issues such as how to manage people's skin integrity, wounds and eating and drinking. Staff understood their responsibility to follow care plans and keep people safe. They told us any changes in people’s risks were shared with them during handovers and daily meetings. One staff member told us, “When we have handover if you’ve been off you learn about new things. Say a resident fell and they need more help, you’d be told in handover and it’s all on the [electronic care plan]. You follow what you’re told to do. That way you are doing things right.” Another staff member commented, “In the care home there could be lots of different risk, but we have lots of equipment to help. Like sensor mats, hoists and roll mats. The nurse does assessments and looks at what equipment is needed to keep the residents safe.” During our inspection we observed staff using appropriate moving and transferring techniques and ensuring people had the equipment they needed to keep them safe. One person told us, “I have to be hoisted now, there is no problem with that.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care. Staff had completed fire safety training and understood what action to take in the event of a fire or other emergency. However, the information staff and the emergency services needed to keep people safe was either not available, not up to date or could not be easily located. During our inspection we identified doors to the sluice rooms on the first floor were not locked, despite signs saying they should be locked at all times. We found items that could be hazardous if ingested in unlocked cupboards in areas accessible to people. The service was experiencing problems with the internal and water temperatures within the home. One staff member told us, “You check the temperature and 10 minutes later it has changed. It can go up or down. It started last year.” No action had been taken to mitigate any potential risks with fluctuations in water temperature whilst waiting for the issue to be resolved. The provider had introduced free standing radiators in some rooms. These radiators were either not covered or the covering was inadequate which meant there was a risk of people sustaining an injury if they fell against the radiators. The registered manager took immediate action to mitigate the risks and assured us work was underway to address issues with the heating and water temperatures. Some people had pressure relieving mattresses on their beds to prevent the risk of skin damage. There was not an effective process to check mattresses were on the correct setting to ensure risks of skin damage were mitigated.

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. People and their relatives were generally positive about staffing levels and raised no concerns about the skills and knowledge of the staff team. However, some people reflected that staff did not always have time to spend with them outside the delivery of care tasks. One person told us, “Most of the time there is enough staff. I think the staff are very competent.” Another person told us they sometimes had to wait for support, “Because they could do with more staff, it is the same at night.” Throughout our inspection we saw staff were available to respond to people’s needs and in the main responded promptly when people used their calls bells for assistance. Staff described safe staffing levels but told us they could be very busy at certain times of the day. Comments included: “We never work short except in an emergency, say someone goes off sick part way through a shift, but then the nurses help out” and “We could always do with more staff as sometimes it is hard as so many residents are in bed. If 2 staff are with them, then sometimes the other residents have to wait. But being honest, I think we do okay.” The registered manager told us they regularly reviewed people’s dependency levels and would not hesitate to request additional staff if a need was identified. They gave examples of implementing 1 to 1 staff support to keep people safe. New staff received an induction into the service which included training appropriate to their role. The provider required staff to regularly refresh their training and monitored staff practice to identify any training needs. The provider’s recruitment processes ensured checks were carried out to ensure the suitability of staff before they started working in the home.

The provider did not always assess or manage the risk of infection. Overall, the home was clean and well presented. However, we found equipment in use in the unit kitchenettes needed cleaning. For example, the inside of microwaves and fridges and the inside of a hot food trolley. We also found some food had not been labelled with the date of opening in accordance with good food hygiene practices. Staff had received training in infection control. They had access to and were observed wearing and correctly disposing of personal protective equipment. One staff member told us, “We have gloves, aprons and masks. We don’t always wear a mask but if someone has an infection, or if lots of the residents were unwell, then we would wear them. That helps keep the residents and staff safe and can stop things spreading.” The provider had processes to share information about any infectious outbreaks in the home. One staff member told us, “If there was a big outbreak we would be told at handover when we come to work. The nurses would make sure we knew. You have to follow good practice like you were shown in training, and you would be extra careful by wearing a mask. It would be like COVID when the resident had to isolate, and only certain staff went in.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff followed best practice guidance in their management of people’s medicines. Storage arrangements for medicines were well managed. This included stock control and ensuring medicines were stored in accordance with manufacturer’s guidance. Clinical staff ensured people received their time critical medicines as required and there was guidance to inform staff when ‘as required’ medicines should be administered. Medicines administration records were well ordered and there were no gaps which indicated people had received their medicines as prescribed. People raised no concerns in relation to the management of their medicines and told us they were given pain relief when they needed it. A typical comment was, “My medication seems okay. They give me pain killers if I am in pain and sort me out.”