Stafford Hall

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

People received safe care and treatment from staff who understood their healthcare needs and followed healthcare guidance from professionals. Staff knew how to safely support people around their individual risks. At the last inspection, published December 2022 the provider was in breach of regulations because they failed to ensure appropriate and safe staffing in the home. Staffing and management oversight had improved so people’s experience of care overall improved. The provider ensured people were safe and received care which met their individual needs, protected their rights, and safeguarded them from abuse and neglect. Medicines were managed safely by competent staff. The home environment was safe, and staff followed good infection prevention and control practice.

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.

People told us they felt safe living at the service. People told us they could make complaints and would be listened to. One supported person told us they attend residents meetings and inform decisions about the menu choices.

The registered manager analysed incidents, accidents and complaints to identify any common themes, patterns and lessons learnt. Action was taken to address lessons learnt, this included reviewing people’s care needs following a fall to reduce this risk.

There were clear processes in place to record incidents, complaints, and compliments. Clear processes in place to investigate, analyse and learn from incidents. Lessons learnt were discussed during staff meetings, enabling staff to reflect and share ideas of how to improve things further.

People and their relatives told us staff supported them to access different health and social care services when needed and their care was well coordinated.

The registered manager explained how they communicated with other services, assessed, and reviewed people’s needs and ensured smooth transitions between healthcare services. There was an admissions policy in the registered managers office and the manager explained they choose not to fill the service to full capacity so people can have better continuity of care. A commissioning authority who had recently audited the service told us they have no concerns about Stafford Hall.

People’s changing needs and new admissions were discussed within the staff team during regular meetings, care was well-organised and monitored daily. When needed, referrals were made to other services, such as GP, district nurse teams, speech and language therapy or social services for additional help.

People and their relatives told us the home was safe. One person said, “Yes, broadly speaking [relative] is safe, been at Stafford Hall for almost 2 years.” Another person said, "Prior to coming here [relative] was dying and being cared for by the community palliative care team who sent [relative] here a year ago as [relative] given up after mum died. The transformation has been remarkable which has been a revelation for the family. [relative] is safe and the quality of care is great.” One family member told us how the service had responded quickly to put measures in place to avoid allergic reaction with foods. Staff treated people well, with kindness and attention. People were not unnecessarily restricted. There were positive interactions between staff and people. The registered manager made it easy to follow how incidents linked to lessons learnt, it was clear to see how good practises were being followed in the managers documentation around safeguarding matters.

Staff could identify signs of possible abuse or neglect and were aware of their responsibilities. Staff told us how they would recognise someone may be at risk and signs to look out for. One staff member said, "Safeguarding from abuse means being vigilant for abuse, keep your eye out for any new skin tears, bruises, scratches that don’t seem familiar, listen out for rudeness. I would report to the manager or to Essex local authority, the police or CQC." Another staff member said, “Safeguarding is about reporting issues or whistleblowing. I would report to the manager or head office. It also depends on the situation; I might need to report to the local authority or CQC."

The provider had a clear safeguarding policy in place and guidance for staff on how to raise concerns. Incidents, accidents and staff feedback were reviewed and acted on. When required, the registered manager investigated safeguarding concerns, worked well with the local authority and took action to protect people from harm. Deprivation of liberty safeguards applications were submitted to the local authority when people’s liberties were restricted to receive necessary care and treatment. This was monitored by the registered manager and reflected in people’s care plans.

Families were aware of health related risks such as weight loss, falls and skin integrity. Families told us of measures put in place to reduce risk such as district nurse visits, referrals and pressure relieving mattresses.

Staff knew people’s individual risks and how to support them safely. Staff commented, “We need to consider their best interests and follow their mental capacity assessments and risk assessments." Staff showed us how to access risk assessments on a handheld device they carry with them on shift.

Staff supported people to remain safe and well and were aware of potential risks. For example, we saw a staff member patiently encouraging one person to eat lunch, they offered a verity of different options including foods not on the menu. They respected the person wishes to decline and ensured lunch would remain warm for them if they changed their mind. We also observed one person walking with bear feet, increasing the risk of falls. Staff were quick to support and get slippers to aid mobility. Another person got up and started to walk without their walking frame; staff were quick to assist to reduce the risk of falls.

People received care in an environment that was safe, clean, and homely. One person said, “It’s a home from home.”

Staff were aware of safety procedures and their responsibilities around maintenance and health and safety in the home. The registered manager told us a new maintenance person is due to start work after pre-employment checks. The service was being supported by a central maintenance team.

The environment was safe and well cared for. Care equipment we saw was in good working order. There was no clutter, and the home was accessible for people with mobility needs. There was a beautiful garden at the rear of the service that was accessible, with measures in place to keep people safe between differing levels of the ground.

The registered manager ensured health and safety and maintenance checks were regularly completed and appropriate certification was in place. Personal emergency evacuation plans and fire safety measures were in place. The provider had a business continuity plan which provided guidance on contingency plans in case of various emergencies and untoward events that could affect the service.

Supported people were involved in interviewing as part of recruitment. A family member said, “Staff are excellent.” Another said, “They never know when you’re going to turn up and every time I go, they are helping people and they use their voices to encourage people. It has a nice atmosphere.”

Staff we spoke with told us staffing in the home had improved since the last inspection. One staff member said, “This inspection is very important to us, so we are glad you are here to see what we are doing.” Another staff member said, "Personally, I like the balance of dependency here, in some places it can be too high." Staff told us they felt they could meet peoples needs and promote independence.

The registered manager made sure there was always staff in the lounge with people. Staff were kind and treated people like family, one person said, “Its like having lots of grandparents, we are like one big family.” Another staff member said, "For me the best thing is when people show their appreciation, then I know I made a difference to their life. A good quality of life is what is important." We observed people taking part in a number of activities and staff adapting to people's needs. People were supported to move around the service freely and encouraged by staff to enjoy their day. Everyone who needed support with eating in their room, was assisted by staff who took their time to help people to enjoy their meal. Staff were offered choices of drinks during the day.

Staff training was reviewed to ensure staff had the knowledge and skills to meet people's needs. Staff were up to date with training. New staff were recruited following a robust recruitment process and a Disclosure and Barring Service (DBS) check. DBS provide information including details about convictions and a Disclosure and Barring Service (DBS) check. DBS provide information including details about convictions and cautions ha Disclosure and Barring Service (DBS) check. DBS provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff knew how to protect people from the risk of infections. One staff member said, “I like to keep peoples rooms clean and tidy.”

The home was very clean. The laundry was managed safely. Staff were observed to wear personal protective equipment when required, hand sanitiser was available. The registered manager completed regular IPC audits and where improvements were identified, action was taken.

Staff were able to explain practises to manage peoples medicine and reduce risk of errors. Staff were aware of peoples rights to decline medicine and best practice to support this.

Medicines were stored safely. Staff completed appropriate records when supporting people with their medicines and there were regular audits in place. ‘When required’ and controlled drugs were managed in a safe way. The provider had a medicines management policy and staff’s competency was assessed. Families told us they had no concerns about how medicines were managed. One family member told us their [relative’s] seizures have decreased as a result of medicines being managed well. Another said, “staff are on top of medication, no issue with it.”