CQC report explained · a nursing home
What the CQC found at Safe Harbour Dementia Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2018
Rated Good; inspectors found kind, safe care, with some records and complaints information needing improvement.
Inspectors visited on 7 and 8 February 2018. The first day was unannounced. They spoke with people living at the home, relatives and staff. They observed care and checked care records, medicines, staff records, safety records and management systems.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, clean premises and good support for people's health, nutrition and hydration.
Staff were described as kind and caring. People had choices, personalised information and social activities. The home had improved its monitoring systems since the previous inspection, when it had breached Regulation 17.
There were still some weaknesses. Training and supervision records were incomplete when inspectors first checked them, some emergency information and care records needed updating, and the complaints procedure was too long and unclear. The manager supplied further information after the inspection about staff training and supervision.
Enough staff
Inspectors found enough staff to provide care, including extra staff for people who needed one-to-one support. Use of agency care staff had reduced.
“During our inspection we found that there were enough staff and the use of Agency staff had reduced.” from the report
Kind and respectful care
Staff spent time talking with people and offered calm reassurance. Inspectors saw respectful care that protected people's dignity.
“We observed positive and respectful interactions between staff and the people who used the service and their relatives.” from the report
Activities and choice
People could choose how they spent their time. Inspectors saw group activities, singing, dancing and use of the garden and animals.
“During our inspection we saw people engaging in and enjoying group activities.” from the report
Improved oversight
The home had introduced audits and checks covering medicines, care files, accidents, hygiene and safety. This addressed the previous Regulation 17 breach.
“During this inspection we found that improvements had been made to meet this requirement.” from the report
Support with nutrition
People had access to drinks and extra support where needed. Inspectors saw that action had helped one person regain weight after weight loss.
“Records showed that with staff support the person had gained weight.” from the report
Emergency information
needs fixingSome personal emergency evacuation plans had not been reviewed since December 2017, and the emergency folder lacked some telephone numbers. Inspectors were unsure whether the plans were current.
“The date of the last review of these was 29/12/17 so we were not sure if they were up to date.” from the report
Incomplete staff records
needs fixingTraining, supervision and appraisal records were incomplete when checked. Further information was sent after the inspection to show that important training and supervision had taken place.
“The training records we looked at during the inspection were incomplete, but following the inspection the manager sent us further information” from the report
Complaints information
minorThe complaints procedure was 11 pages long and did not clearly explain who to contact. The manager agreed to make it clearer and shorter.
“This ran to 11 pages and did not give clear information to people” from the report
Care plan update
minorOne care plan listed equipment that was no longer used or had been replaced. Staff knew about the change, but the written plan needed updating.
“We asked a senior member of staff to make sure the person's plan was updated to reflect this.” from the report
Privacy of information
needs fixingA whiteboard contained confidential information and was in a room that visitors sometimes entered. Staff said they would prevent visitors from using that room.
“As this means they may see the information on the whiteboard the senior member of staff said they would in future ensure visitors did not use this room.” from the report
- 01How do you check that personal emergency evacuation plans and emergency contact details are current?
- 02How do you keep care plans updated when equipment or a person's needs change?
- 03Can you show us the current complaints procedure and explain who families should contact?
- 04How do you record and monitor staff training, supervision and appraisals?
- 05How is confidential information protected from visitors in staff areas?
This was an inspection of the overall service covering all five CQC questions, including the building and the care provided; it followed a previous Regulation 17 breach that inspectors found had been addressed. This explanation was written from the published report of 6 March 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2017
Safe Harbour Dementia Care Home was Rated Requires Improvement; inspectors found kind, person-centred care but safety and management checks needed strengthening.
This was an unannounced inspection on 24 February and 2 March 2017. Inspectors spoke with people living at the home, relatives, staff and a visiting health professional. They observed care and checked care plans, staff files, medicines records, rotas and management records.
The home was clean and well maintained. People were treated kindly and with dignity. Inspectors found good support with health needs, food, personal choices, activities and care planning. However, some medicine records were incomplete, recruitment checks were not always fully followed, and some risk assessments did not give an accurate picture of people's needs.
The home was rated Good for Effective, Caring and Responsive. It was rated Requires Improvement for Safe and Well-led, leading to an overall rating of Requires Improvement. The report identified one breach about checking and monitoring the quality and safety of the service.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed kind, courteous and dignified interactions.
“Staff spoke and interacted with people in a kind and dignified manner.” from the report
Personalised care
Care plans contained detailed information about people's histories, preferences, communication and support needs. Relatives were usually involved in planning care.
“Care plans contained details that were important to people.” from the report
Activities and interests
The home offered group and one-to-one activities, including music, trips, crafts and pet therapy. Activities were adapted to individual interests.
“There was a mix of individual and group activities both in and outside of the home.” from the report
Clean and maintained environment
The building was clean, fresh smelling and well maintained. Equipment and safety checks were recorded.
“The home was clean and fresh smelling.” from the report
Support to reduce falls
The home used care plans, sensors, protective equipment and advice from specialist professionals to reduce the risk and effects of falls.
“This helped to keep people safe and to reduce the risk of falls.” from the report
Medicine recording errors
seriousOne medicine stock record was incorrect and there were three unexplained gaps where administration should have been signed. This could make it difficult to confirm whether medicines had been given.
“For two other people the records had three unexplained blanks where the nurse should sign to say the medication had been administered.” from the report
Agency nurse oversight
seriousA large amount of nursing care was provided by agency nurses. The clinical lead did not have enough allocated time, and there was no clear plan for overseeing agency nursing practice.
“There was no system in place or plan outlining how the clinical lead would fulfil their role of overseeing the nursing practice of the agency nurses.” from the report
Recruitment checks
seriousSome recruitment checks were incomplete. One reference had not been verified and another had not been obtained from a relevant previous employer.
“We saw that staff had not always been recruited in a safe way that ensured they were suitable to work with vulnerable adults.” from the report
Care risk assessments
needs fixingSome screening tools were completed incorrectly. In one example, a person at high risk of falls was recorded as not being at high risk.
“A person who was at high risk of falls was showing on the assessment as not being at high risk of falls.” from the report
Staff supervision and appraisals
needs fixingThere were gaps in staff supervision and annual appraisals. The report also found that management audits had not identified these gaps.
“The records also showed that many staff had not received an annual appraisal.” from the report
- 01How are medicine administration records checked now, and how are missing signatures or stock discrepancies dealt with?
- 02What has changed in the induction, handover and supervision of agency nurses since this inspection?
- 03How do you make sure recruitment references, especially from health and social care employers, are verified before staff work here?
- 04How are falls, nutrition and other risk screening tools checked for accuracy?
- 05Have all staff received the planned supervision meetings and annual appraisals?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 16 June 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Safe Harbour Dementia Care Home
3 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Safe Harbour Dementia Care Home →
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Safe Harbour Dementia Care Home →
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015
Registered with the Care Quality Commission on 14 August 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £980 to £1,230 a week. 37 can care for a couple. 8 years' experience on average.
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