Paisley Court

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. Some care plans contained conflicting or missing information. Safety measures, such as applying brakes on beds and chairs, were not always followed and blocked fire exits, and unlocked sluice room doors were recurring issues. All these shortfalls were immediately addressed by the manager when we raised them. Improvements were needed to ensure staff had completed all their training and some staff reported occasional staff shortages. While most people and families found the home clean, some concerns were raised about bedding hygiene. Some improvements were needed around the safe management of medicines. Actions were taken to address all of these findings. Safeguarding concerns were managed and investigated well; however, there was a delay in reporting an incident observed during our visit. Managers acted immediately, addressing the issue with the staff involved.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For example, one person’s level of support was increased after a series of incidents to ensure their safety. Accidents and incidents were analysed monthly to identify patterns and trends, with learning shared through one-to-one discussions, team meetings and smaller group huddles. Additionally, staff involved in incidents participated in debriefs and reflective practices to support ongoing improvement.

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. Before admission, a thorough assessment was conducted involving the person, family and relevant professionals. Information was effectively shared between services and accurately reflected in care plans, which made transitions smooth. For example, one person’s assessment included input from staff at their previous service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did not always share concerns quickly and appropriately. For example, we observed a delay in recording and reporting of an incident which occurred during our visit. Managers addressed this immediately and conducted reflective practice sessions with staff members involved to prevent recurrence.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive. For example, safety measures were not always followed by staff. We observed brakes on beds and chairs not being applied. Managers reinforced the importance of these measures during daily flash meetings. Families were involved in the review of care plans each month, which provided guidance on managing specific risks, such as diabetes, however, some contained conflicting or missing information which made risks unclear to staff. These care plans were promptly updated by the manager. Furthermore, some staff training was overdue, for example, falls training. The provider had an ongoing plan in place to address this and ensure all staff training was completed.

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, we observed recurring issues, including blocked fire exits and sluice room doors left unlocked. In response, managers implemented additional measures, such as placing clearer signage on doors, increasing the frequency of daily walkarounds, and addressing these concerns with staff in daily meetings.

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. Some staff told us they were sometimes short staffed; however, others recognised an improvement in staffing levels. One staff member told us, “We are getting new staff and lots of interviews happening.” Staff were recruited safely and provided with a thorough induction.

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. While most people and their families described the home as clean, one professional raised concerns about personal hygiene and cross contamination. This was raised with the registered manager who provided assurances. A family member highlighted concerns regarding the cleanliness of bedding. Managers assured us bedding was changed and washed daily. However, an additional daily check was introduced for laundry staff to document and confirm when each person’s bedding had been cleaned and replaced.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. There was an auditing process in place; however, we identified some areas for improvement. Opened creams were undated and stored inappropriately, with no risk assessments in place. Some medication instructions lacked clarity. For example, a person’s eye drops did not specify which eye they should be administered in. There were delays in ordering some medicines, and the electronic medications management system was not always updated promptly, such as when medicines were discontinued. The manager was already aware of some of these concerns, and they had been included in an action plan for resolution.