• Care Home
  • Care home

South Collingham Hall

Overall: Good read more about inspection ratings

Newark Road, Collingham, Newark, Nottinghamshire, NG23 7LE

Provided and run by:
Broadoak Group of Care Homes

Report from 12 June 2024 assessment

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Safe

Good

Updated 31 October 2024

People and those important to them were supported to understand safeguarding and how to raise concerns when they didn’t feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. However, we found reviewing of incidents needed further work to ensure future risks were reduced. The risk assessments in place were inconsistent. Some risks were documented clearly whereas others were not. There were enough staff to support people with their personal care needs. However, staff vacancies had impacted staff’s ability to complete social activities with people. Managers reviewed staffing levels regularly to make sure there were always enough suitably skilled and experienced staff on duty. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service. People told us they received their medicines safely. Processes in place needed embedding to ensure the safety and management of medicines. People told us the home was clean and tidy.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning culture

Score: 3

People consistently told us they felt South Collingham Hall was a safe place to live. We spoke with 4 people and 12 of their relatives, who all told us they were supported safely. Several relatives we spoke with told us, if incidents occurred, staff reported these to them and communicated what action they had taken to prevent accidents happening again.

Staff we spoke with told us they were informed of incidents during handovers and any risk reduction measures were discussed. Staff told us they were well supported to develop their learning. A staff member said they had been supported to enrol on a course to develop their skills to further enhance the safety of the service. The provider explained they had recently identified issues within the leadership team and took decisive action to address the issues to ensure lessons were learnt.

There were not always clear processes in place to identify themes and trends of incidents and accidents which meant there were missed learning opportunities. Whilst some incidents had been recorded there was not always a resolution documented to detail what staff had done to reduce the risk of incidents happening again. There was a complaints policy in place to guide staff however this had not been reviewed recently which meant some of the details were not accurate.

Safe systems, pathways and transitions

Score: 3

People told us communication between staff at South Collingham Hall and other health providers was good. Relatives we spoke with praised the home for the level of communication in regard to health appointments. A relative we spoke with said, “The explanation of my [relative’s] nursing needs is communicated well.” Another relative we spoke with praised the staff for supporting their relative with specialist hospital appointments.

Staff had good knowledge of which health and social care professionals supported which people. Staff were able to explain when these professionals visited, and what type of support they offered. For example, staff we spoke with told us who required support from the community nursing team and how they referred into this service. Staff knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example. We observed a person who had become unwell, staff responded quickly and contacted an appropriate healthcare professional to ensure timely care and treatment was sought. The person was closely monitored by staff whilst waiting for specialist support. The manager told us they were in the process of reviewing all care plans in collaboration with people and where needed their representatives to ensure they were accurate and personalised.

We spoke with two visiting professional who told us communication was good. A professional we spoke with said the good communication between themselves and staff provided a supportive and integrated community service.

Staff kept clear records on people’s needs. Records relating to periods of distress and anxiety were particularly detailed. This meant other professionals such as doctors and the dementia outreach team could make an accurate assessment in order to provide safe care and treatment. Where people required external health and social care support, records showed specialist support had been sought and implemented into care plans. For example, records detailed advice from a specialist nursing team had been implemented into a person’s care plans.

Safeguarding

Score: 3

People told us they felt safe living at South Collingham Hall. A person we spoke with said, “The care is very good here” and another person said, “The staff are amazing I feel very safe here.” Relatives we spoke with told us they felt their loved ones were protected from the risk of abuse and neglect. A relative said, “The staff are great, my [relative] acquired pressure ulcers whilst in hospital, but the carer’s attention has sorted these out.” This demonstrated staff protected people from the risk of neglect through effective pressure area care.

Staff understood how to respond to allegations of abuse. The provider and manager were aware of their duty to protect people from the risk of abuse and neglect. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. The manager understood how to respond to allegations of abuse. They were in the processes of reviewing safeguarding processes to ensure no incidents were missed. The manager told us they had support from the provider and a registered manager from one of the providers other services to strengthen their knowledge. Staff knew where to find the safeguarding policy. They were aware of the policy guidance and knew how to follow it to keep people safe from potential abuse.

We saw people and staff had positive relationships. People appeared relaxed in staff’s company. We observed warm and friendly interactions between staff, people, and visitors.

If an allegation of abuse was made, there was a policy in place to guide the staff team. Whilst records showed incidents were investigated and referred to the local authority safeguarding team, there were no ‘lessons learnt’ documented or what action the service had taken to reduce the risk of recurrence. For example, an incident we reviewed following a fall had a limited investigation. This incident had occurred prior to the current manager starting and the provider had addressed poor reporting and taken action prior to our assessment. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we found staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty. Whilst they had been applied for, we found the documentation to monitor the expiry dates of authorisations was not updated. This meant there was a risk these would expire and not be reapplied for; this is not line with legislation. The manager told us they were in the process of updating this record.

Involving people to manage risks

Score: 3

People were supported safely by staff who knew them well. A person we spoke with said, “They definitely look after me well here. I very much like it here.” A relative we spoke with told us they were involved in their loved one’s care. “This care home is amazing. The staff are so lovely with [relative], and they involve me fully in their care needs. I wouldn’t want them to go anywhere else.” People told us they were able to communicate their needs and use their call bell to request support when needed.

Staff knew people’s needs well and how to support risks safely. Staff were aware where to find care plans and risk assessments. Staff told us the management team acted quickly when equipment was needed to keep people safe. The manager informed us of equipment they had ordered for a person following a fall. This equipment would alert staff if the person attempted to stand without support. This meant the manager was aware of the importance of risk reduction measures being implemented.

We saw people were supported safely. We observed staff supporting people during lunch time using safe techniques. We observed staff to use moving and handling equipment safely.

People had care plans in place, however these were not always detailed to ensure staff had accurate information in order for staff to support them safely. For example, a risk assessment in place relating to diabetes was unclear, however, this appeared to be a documentation issue as staff were able to tell us in detail about the person and how they support them to manage their diabetes. We found other risk assessments required further work to ensure staff had clear information to support people safely. For example, records relating to skin integrity for one person were unclear. This increased the risk of staff not providing the right level of support to the person. Staff kept records on how they had supported people and at what time. This allows changes in a person’s needs to be identified. There were risk assessments in place for people which instruct staff and emergency services how to support people safely in the event of an emergency.

Safe environments

Score: 3

People gave us mixed feedback about their environment. Some people told us they were happy with the environment and told us it was safe and homely. Others told us they had concerns about the outside environment such as the patio area being unsafe, and gardens were accessible for everyone. People told us they had access to a call bell in their bedrooms to call for support from staff which made them feel safe.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns too. Staff told us, “Any problems that occur are soon sorted by the manager, any new equipment we need, we get quickly.” The management team described a clear process for monitoring the safety of the environment. Staff were aware of their responsibility to ensure the environment remained safe for not only people living at South Collingham Hall, but also staff and visitors.

Some people at the care home used equipment such as walking frames and wheelchairs. We found this equipment to be well maintained and stored appropriately. We observed a member of the maintenance team fixing a fire door which had been reported on the day of the assessment. This ensured South Collingham Hall remained safe in the event of a fire. Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the health and social care executive.

Processes in place meant the environment was kept safe. Designated staff completed regular checks of the environment and equipment. We found there had been monthly checks of equipment such as bed rails. Regular checks of equipment meant they remained safe for people to use which reduced the risk of harm. Servicing of fire alarms, electrical and gas systems were carried out by qualified contractors. This ensured systems remained in safe working order and reduced the risk of harm to people.

Safe and effective staffing

Score: 3

People told us they were supported by kind staff who knew them well. People and their relatives did not raise any concerns relating to staffing levels to keep them safe however they did feel more staff were needed to provided social stimulation. People told us staff supported them in a timely manner. We received positive feedback about all the staff and the support they provided. A person we spoke with said, “The staff are gentle and caring. I would recommend this home.” However, people did raise concerns relating to staff’s ability to provide social opportunities as there were no dedicated staff to arrange activities. A relative we spoke with said, “During last year there were occasional outside activities which [relative] enjoyed, for example a beach party in summer, and participating in some games. But now the absence of an activities coordinator is a big loss.” Another relative we spoke said, “I wish there could be more suitable activities.”

Staff and the management team recognised the absence of an activity coordinator had on people. Staff we spoke with said, “We could really do with an activities coordinator.” The management team told us they had a small number of vacancies they were actively recruiting for including an activities coordinator. They discussed the difficulties of trying to recruit staff but displayed a committed attitude of recruiting the right staff for the home. The manager was new into post and recognised staff needed supervision meetings organising as these were overdue. Supervision meetings gave staff the opportunity to feedback about their experiences and request further guidance and training if needed.

We found there were enough staff to provide support to people safely with their personal care needs. Staff were deployed effectively around the building, to provide timely support to people. However, for a small period during lunch some people had to wait longer than others for their lunch as staff were supporting people with their meals. This was discussed with the manager who told us they would review the lunch time experience. We observed any requests for support were answered quickly by staff. We also observed staff were suitably trained to complete their roles. Staff used their training to respond effectively to people’s needs.

Processes in place ensured there were enough suitably trained staff on duty. There was a dependency tool in place taking into account people’s individual needs. This determined how many staff were required each day in order to support people safely. Staff were recruited safely. Processes in place ensured necessary checks were completed prior to staff starting at South Collingham Hall. This included reference checks, proof of identity as well as Disclosure and Barring Service (DBS) checks. A DBS check is a way for employers to check an employee criminal record, to help decide whether they are a suitable person to work for them. This protected people from receiving support from unsuitable staff. Staff completed training to ensure they supported people safely.

Infection prevention and control

Score: 3

People and their relatives told us the home was always clean and tidy. A relative we spoke with said, “I am impressed with the cleanliness and the recent redecoration.” Another relative we spoke with said, “Cleanliness is superb. The home is bright and airy and there are no smells.” A person we spoke with told us staff supported them to maintain their personal hygiene. This reduced the risk of potential infection.

Staff understood their responsibility to protect people from the risk of infection. Staff told us they were happy with the training provided and knew when to wear personal protective equipment to protect people from the risk of infection. The management team discussed lessons they had learnt following infection control audits from commissioners, they told us they had found these helpful in improving the infection control standards at South Collingham Hall. Staff working in the kitchen understood their role in infection prevention and control, they explained how they ensured the kitchen area remained clean and tidy. This reduced the risk of the spread of infection.

The home was clean and tidy. We found staff had access to personal protective equipment and wore it appropriately when supporting people. This ensured staff supported people in line with best practice guidance. We observed designated housekeeping staff to be completing their roles thoroughly. We found the kitchen was clean and managed safely. This decreased the risk of people contracting food bourne infections. The most recent check from the food standards agency, had rated the service 5 stars on the 4 October 2023.

There were processes and policies in place relating to infection prevention and control. However, there had been a number of recent changes to the management of the service which meant audits were not consistently completed. We also found whilst staff were completing cleaning schedules no one from the management team were reviewing these to ensure staff were completing their duties effectively. Further work was required to ensure processes were fully followed to ensure they were effective. Staff completed training in infection prevention and control and a policy was in place to guide staff in the event of an infection outbreak.

Medicines optimisation

Score: 3

We received no negative feedback from people or their relatives regarding medicines. People and their relatives were confident in staff’s ability to escalate any concerns to health care professionals when needed.

Staff told us that they completed training to safely provide support to people with medicines. Staff were able to explain the electronic system in use and how they supported people to take their medicines safely. Staff explained they were about to change to paper-based medicine records due to issues encountered with the electronic system. The management team explained the changes were to be implemented after discussion with the staff team. Staff explained they were receiving support from the pharmacy to implement the changes safely.

Processes in place needed strengthening to ensure people were protected from the risk of receiving their prescribed medicines unsafely. Audits were not always effective in highlighting issues. For example, we found recording errors on medicine administration records which had not been picked up. We also found there had been errors of recording the amount of stock available and this had not been picked on medicine audits. Staff explained there had been issues with the electronic system which often recorded incorrect stock levels. This was one of the reasons for deviating away from the electronic system. The management team recognised this and were responsive to our feedback to ensure the management of medicines improved. People had medicine administration records in place which detailed how they like to take their medicines and what support they needed. This meant staff had accurate information in order to support people safely. We found medicines to have opening dates documented which meant staff knew they were safe to use. Medicines were stored in a locked area, to prevent people accessing them unsafely. Controlled drugs were stored according to guidance. Staff completed regular checks for controlled drugs. Controlled drugs are subject to government restrictions due to the risk of harm and/or addiction. Completing regular stock checks of these medicines, provides assurances of management of these high-risk medicines.