CQC report explained · a residential care home
What the CQC found at Saffron House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Rated Requires Improvement and placed in special measures; inspectors found unsafe medicines and risk management, with Safe rated Inadequate.
This was an unannounced focused inspection on 22 November 2023. Inspectors observed care, spoke with people, relatives and staff, and checked care plans, medicine records, recruitment files, training records and management checks.
The home had not made enough progress since its previous inadequate rating. Medicines were not always stored, returned or recorded safely. Care plans did not give staff enough guidance about supporting people who became distressed, and safeguarding concerns were not always referred or acted on.
There had been improvements to cleanliness, the environment, staffing and medicine systems. However, these changes were not fully embedded. The home was rated Requires Improvement overall, with Safe rated Inadequate and Effective and Well-led rated Requires Improvement.
The home has been placed in special measures because it had an Inadequate rating in a key question over two consecutive comprehensive inspections. CQC said it would monitor progress and usually re-inspect within six months.
Cleaner environment
The provider had made significant improvements to cleanliness and people's accommodation. Some redecoration was still in progress.
“The provider had taken immediate action to improve cleanliness and the standard of people's living accommodation.” from the report
Healthcare links
Staff supported people to see health professionals and included professional advice in care records.
“Throughout our inspection visit, we observed the senior staff on shift communicating with health and social care professionals and ensuring referrals were made to meet people's needs.” from the report
Safe recruitment
The home carried out DBS checks for all applicants as part of its recruitment process.
“The provider followed safe recruitment practices. A check with the Disclosure and Barring Service (DBS) was carried out on all applicants.” from the report
Food and drink support
People had choices of meals and drinks, and records showed support for those at risk of poor nutrition or hydration.
“People were supported to have a choice of meals and provided with a choice of drinks throughout the day.” from the report
Medicines were not managed safely
seriousTablets were found in sharps containers without an audit trail. Some topical medicines had not been signed for, and a medicine trolley was left unattended where medicines could be reached.
“Medicines were not stored, returned or disposed of safely.” from the report
Risks around distress were not managed
seriousCare plans lacked clear strategies about triggers and how staff should respond when people became distressed. Inspectors also saw support during eating that caused distress and presented a possible choking risk.
“There was lack of risk assessment and guidance around the mitigation of risks to keep people safe from harm.” from the report
Safeguarding systems failed
seriousA potential safeguarding incident was not referred to relevant external agencies, including CQC. The home did not show that risks had been reviewed or that action had been taken to prevent further incidents.
“People were not consistently protected from the risk of harm.” from the report
Weak management oversight
seriousAudits did not identify important problems, and improvements were not consistently sustained. The manager did not ensure agency staff received enough guidance and oversight.
“The registered manager had failed to have effective oversight of the service to ensure improvements were made and sustained.” from the report
Staffing and infection control
needs fixingPeople and relatives reported delays in getting help, especially at busy times. Inspectors also found staff awareness of cross-infection risks needed improvement, including unsafe handling of shared cutlery.
“People, relatives and staff felt the deployment of staff was not always sufficient to meet people's needs in a timely way.” from the report
Capacity records were inconsistent
needs fixingSome mental capacity assessments and best-interest records did not clearly explain the decisions made or who had been involved.
“Mental capacity assessments were not always undertaken consistently.” from the report
- 01How are you ensuring medicines are stored, returned, disposed of and recorded safely every day?
- 02What clear guidance is now in each person's care plan about triggers and how staff should respond when they become distressed?
- 03How are safeguarding incidents referred, reviewed and used to prevent further harm?
- 04How do you supervise and check agency staff, especially when they are new to the home?
- 05What are the target dates for completing the remaining environmental and redecoration work?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the report says the other ratings used ratings from the previous inspection to calculate the overall rating. This explanation was written from the published report of 27 January 2024 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, November 2023
Rated Inadequate and placed in special measures; inspectors found serious safety, medicines, infection control and management failures.
Inspectors visited unannounced from 6 to 8 June 2023. They spoke with people, relatives and staff, observed care, checked the building and reviewed care plans, medicines records, training and management checks.
They found people were at risk from poor risk assessments, unsafe medicines procedures, fire safety concerns and insufficient night staffing. Some areas were dirty, unhygienic and unpleasant-smelling. People were also left using soiled mattresses and worn bedding until the inspection prompted replacements.
The home did provide some positive support. Staff were recruited safely, communication needs were supported, people could take part in activities and staff were seen speaking respectfully. However, the overall rating was Inadequate. Effective, caring and responsive care were rated Requires Improvement, while Safe and Well-led were rated Inadequate.
Kind staff interactions
Inspectors saw staff speaking respectfully with people. Most people and relatives also gave positive comments about staff and care.
“Staff interaction was kind and caring. We observed staff spoke with people respectfully.” from the report
Communication support
Care plans included information about communication needs, and staff used communication methods people could understand.
“Staff were seen to communicate with people in a way they understood.” from the report
Safe recruitment
The provider carried out DBS checks for applicants, which inspectors considered a safe recruitment practice.
“The provider followed safe recruitment practices. A check with the Disclosure and Barring Service (DBS) was carried out on all applicants.” from the report
Unsafe medicines
seriousRecords for patches, creams and as-required medicines were incomplete. This meant inspectors could not be sure medicines were being given and monitored safely.
“Medicines were not managed safely. This placed people at risk of harm because staff were not consistently administering all prescribed medicines in line with national guidelines.” from the report
Poor cleanliness and infection control
seriousInspectors found dirty equipment and surfaces, unpleasant smells, soiled mattresses and worn bedding. Cleaning records and action on identified problems were not reliable.
“We identified significant failings with the cleanliness and upkeep of people's living accommodation” from the report
Fire and other risk management
seriousEvacuation plans did not always explain people's needs, and some staff lacked practical training to use an evacuation sledge. A previously identified unlocked bin store fire risk remained.
“This put people at significant risk of harm in the event of a fire or other emergency as staff did not have the skills or information to be able to evacuate all people safely.” from the report
Incomplete care records
needs fixingCare plans were sometimes contradictory, out of date or missing guidance. This included risks such as choking, changed diabetes treatment and end-of-life wishes.
“People's needs were not always appropriately assessed and their needs were not clearly reflected within their care plans.” from the report
Weak management oversight
seriousThe home's checks failed to identify or resolve repeated problems with cleanliness, medicines, risks and records. Some improvements made after the inspection were still not good enough.
“The registered manager and provider had failed to ensure the quality assurance systems were reliable, robust and effective to drive improvements.” from the report
- 01What specific changes have been made to medicines records, including transdermal patch checks, body maps and records of as-required medicines?
- 02How are you now checking that bedrooms, bathrooms, mattresses and bedding are clean and fit for use?
- 03What practical fire evacuation training have night staff completed, and how will you safely evacuate people who need two staff or an evacuation sledge?
- 04How do you make sure mental capacity assessments, best-interests decisions and DoLS applications are completed and followed up on time?
- 05How are care plans kept up to date when a person's health needs or treatment changes, and how are people and relatives involved?
This was an unannounced inspection that assessed all five key questions and included checks of infection prevention and control, care, medicines, staffing, records and the building. This explanation was written from the published report of 18 November 2023 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 Saffron House
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingup from InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2023InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- June 2021Inspected but not ratedSafe: Inspected but not rated
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2019GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018
Registered with the Care Quality Commission on 18 January 2018.
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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