Derby Heights 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 key question has been rated good. People were safe and protected from avoidable harm. Systems were in place to manage safeguarding incidents and staff were trained in safeguarding people from abuse. Risk assessments were in place to reduce people's risk of harm. Care plans provided staff with an overview of people's care needs. Enough trained staff were deployed, and staff received regular supervision and training

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.

We spoke with eight people using the service and three relatives. All of them felt able to raise concerns and felt they would be listened to. One person said, “I think the registered manager will improve things.” One relative told us, “Since the registered manager has arrived the staff seem happier and has pulled everyone together and will do anything for you.”

The registered manager demonstrated a good understanding of learning from accidents and incidents and understood their responsibilities under the duty of candour. We found appropriate actions had been taken to reduce the risk of reoccurrence. The registered manager and provider regularly analysed accidents and incidents to identify any emerging themes or patterns in order to improve the care provided. These findings were then shared with the staff team regularly through meetings. The providers also had systems in place to ensure learning from their other services was shared.

The service had robust systems and processes in place to ensure learning took place following incidents and accidents. The manager shared learning from incidents and accidents in reflective practice session with staff to minimise the risk of reoccurrence and improve staff practices. This information was cascaded through the staff team, so all staff were involved in any reflections of practice.

People told us staff supported them to access medical support when needed.

The registered manager told us how the staff at the service worked in partnership with other professionals such as GP's and community nurses to support people to access healthcare when they needed it. This had improved people's outcomes. The registered manager demonstrated how when a person's needs had changed, they had promptly engaged with many services to ensure the person's needs were fully met and understood.

External health care professionals confirmed working in collaboration with the home. A health care professional stated, ‘The staff know the residents well. They will alert us to residents who are having problems with their medication and helpful when trying to find solutions to these problems.’

We reviewed the providers admission process and found key information was sought from the person, their relatives and any external professional involved in the person’s care to enable a positive transition into the service. We also found the assessment continued following their admission to ensure the service had accurate and up to date information on people's needs and preferences.

People and relatives told us they felt safe living at the service and had no restriction imposed on them. A person said, “I don’t have to do anything I don’t want to. I make all my own choices in the day about when I get up and when I go to bed.”

The registered manager told us how they ensured safeguarding incidents were fully investigated and referred to relevant agencies. Management told us how they ensured learning from these incidents was cascaded throughout the team and the provider’s other services. We reviewed the systems in place to ensure safeguarding incidents were followed up, actioned, and monitored for themes and patterns. We found no issues.

Staff were observed to treat people with care and respect throughout our visit. We observed staff encouraging and promoting people’s choice and staff were observed to know people well and have a good understanding of their needs and preferences.

We found safe systems in place for when accidents and incidents occurred to ensure all occurrences were investigated in a timely manner and referrals to seek advice and support was sought from external agencies when this was required. The provider also monitored these systems to ensure investigations and actions were taken following an incident

Most people told us they received effective support. However, one person told us they did not always feel safe when being supported by staff to move. We discussed this with the registered manager and they took immediate action ensuring safe moving and handling were always adhered.

The registered manager told us how they assessed and monitored risk, for example they reviewed people's weight regularly to identify any cause for concern and had robust processes in place to ensure any risks were mitigated. Staff demonstrated an awareness of how to escalate risks they identified and from the conversations we had it was evident they knew people well.

We observed staff to support people in line with their care plan and risk assessments. Staff promoted people’s choice and independence and we found necessary control measures in place to protect people from avoidable harm.

We found people and their relatives had regular opportunities to be involved in the planning of their care and any associated risks. The registered manager told us how they had introduced a resident of the day system which ensured people and their relatives had regular opportunities to be involved with their care plan and any associated risk management.

People told us the home was clean and they felt safe. A relative said, ‘We’ve never looked back, my relative is safe and cared for and the staff are lovely.’

The registered manager and provider told us about the various systems they had in place to ensure a safe environment, this included daily walkarounds. Staff knew how to report any concerns and the service had an on-site maintenance person who was supported by a wider internal and external team.

We observed the environment to be safe and equipment had been regularly serviced and checked for safety.

Systems and processes were in place to ensure a safe environment. We reviewed the health and safety within the service and found this was regularly checked and compliance certificates were in place and up to date.

Most people told us there were enough staff and they felt safe with them. However, two people told us sometimes they had to wait for the call bells to be answered. We discussed this with the registered manager who confirmed call bells were monitored on a daily basis by them on the ‘daily walkabout.’ However, the registered manager told us they had not received any concerns from people about waiting for a response by staff and will continue to monitor call bell responses.

The registered manager ensured they had correct staffing levels to meet people’s needs. The provider told us how they had worked to ensure the service had regular staffing in place to ensure consistency of care. The registered manager told us how they had identified additional training to enhance staff skills. The service had an onsite trainer who provided training to the team. In addition they identified additional training to enhance staff skills and carried out regular checks of staff competency. Staff consistently told us they felt there was enough staff available to meet people’s needs.

We observed staffing levels to be suitable to meet the needs of people using the service. Call bells were answered in a timely manner and staff were available to assist people when they needed support.

Staff were recruited safely; safer recruitment processes had been followed to ensure people were suitable for their roles. The manager had a dependency tool in place which ensured the needs of people were regularly reviewed to ensure suitable staffing levels were in place. The service also employed wellbeing staff and hostesses which complimented the care provided.

People raised no concerns about infection control and told us staff used personal protective equipment (PPE). One person told us, “The home is very clean and my bedroom is cleaned every day. The staff always wear PPE.”

Staff demonstrated an understanding of the steps they could take to reduce the transmission of infection; the registered manager told us of the control measures they had in place and how the service had recently had an external IPC audit which they were compliant with.

People were protected from the risk of infection, infection, prevention control measures were seen to be in place and followed by staff.

Procedures and processes were in place to prevent infections in the home, which were followed by staff.

People told us they received their medication on time. People were supported to take their medicines in a safe way by staff who were trained. One person told us, “My medicines are given to me every day, they don’t forget.”

The registered manager and staff we spoke to told us how they ensure people received their medicines safely and in line with the prescriber’s instructions. Staff knew what to do in the event of a medicine error and told us their medicine administration competency was regularly checked.

Medicines were managed safely, stock levels corresponded with the records in place. However, we found staff did not consistently record the reasons ‘as required’ (PRN) had been administered or the effect this had. The manager took immediate action to address this with staff when we raised it. PRN protocols provided person centred detail on when PRN should be offered or administered which included the signs/behaviours people presented with when in pain.