Northway 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. This is the first inspection since the service was registered to the provider Pebblestones Limited. 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. The service was in breach of regulation in relation to the safe management of medicines.

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 service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Learning was not always put into practice to make sure improvements were made. For example, although the manager reviewed all incidents and accidents on a monthly basis and some lessons were learnt, it was not always clear how this learning was shared with staff. For example, where it was highlighted people required to be more closely monitored to minimise risks it was unclear how staff were made aware of this need.

The service 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. The manager liaised with other professionals. This included carrying out pre-admission assessments before people moved to the home.

The service 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. The service shared concerns quickly and appropriately. People felt safe at the home. One person told us, “I feel safe here. Just press the button and someone will come. They are very caring.” A relative told us, “I never go away worried. I know they are in safe hands.” Managers made sure they protected people’s liberties and rights under the Mental Capacity Act. Applications were made for people to be legally deprived of their liberty where they needed that level of support to keep them safe.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The quality of risk assessments was variable. We saw some assessments which were comprehensive and showed actions to be taken to minimise risks. However, some required risk assessments were not in place. For example, one person’s care record showed they had become anxious and upset when they were unable to leave the home to follow an interest without staff support. However, there was no risk assessment and no information about how the person could be safely supported to take part in their hobby following this incident.

The service 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. Environmental checks were recorded in several different places and therefore it was not easy to follow what safety checks had been carried out in house and by outside contractors. Some checks had not been undertaken and the provider arranged for these to be carried out after the site visit.

The service 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. The service had sufficient staff to meet people’s needs. One member of staff told us, “The ratio of staff to residents is good.” Staff had received training to make sure they had the skills needed to safely support people.

The service 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. Equipment and premises were mostly clean and well maintained, reducing any risk of infection. However, some cleaning schedules had not been completed which potentially placed people at risk. This had been identified but not addressed by the provider.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Staff were not following the medicines policy in the home. For example, medicines were not always being administered according to the prescribers’ instructions and staff did not understand the significance of this. Appropriate records of medicines administration were not always being kept to evidence people received their medicines. The provider had also failed to ensure risk assessments were not in place for high-risk medicines such as anticoagulants and flammable creams and staff were not always aware of these risks. This placed residents at risk of harm.