Sowerby 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

We identified 3 breaches of the legal regulations. Care records were not always accurate or complete. They were not sufficiently detailed, personalised, or regularly reviewed. Where people’s care needs had changed, their care plans had not always been updated to reflect this change. People and relatives were not always included in the development of care plans. People’s daily care records did not always show how their risks were being managed in line with their assessed needs. There were ongoing concerns with medicines management and administration. We found infection prevention and control (IPC) did not give people care and support in a safe, clean, well equipped, well-furnished and well maintained environment that met their sensory and physical needs. Some areas of the home were visibly dirty. People received the care and support, however, staff did not always have time or were not always able to respond to people's presenting or changing needs. All required pre-employment checks were completed prior to people starting to work at the home. We observed interactions with people were friendly. Feedback from people and their relatives was mixed in terms of the consistency. People and staff spoke positively about the management of the service.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One person told us that if they raised any concerns with staff action would be taken. They said, “I’d ask to speak to the Manager but since I was moved here things haven’t been too bad.”

Staff we spoke with, told us processes were in place to manage concerns but said they thought feedback with remedial actions could be improved. The registered manager said, “We investigate and respond to all concerns. We have a new area manger and will be reviewing information at a provider level to promote learning across services.”

Records of accidents and incidents analysis were not always complete. Actions were not always formulated to evidence action taken to mitigate future risk.

People were supported to access healthcare, such as GP’s and district nurses. Equipment provided to support people was not always used as designed. For example, pressure mats where not always used correctly.

People were supported from a range of professionals to meet their individual needs. Staff discussed how they shared concerns with district nurses and the importance of maintaining good relationships to ensure external advice was discussed, recorded and implemented to help people maintain and improve their health and wellbeing.

A community nurse told us, sometimes the cleanliness of the rooms is poor and some people have pressure damage, but do not have any significant concerns for people.

Records reviewed showed referrals to other professionals were complete, such as dieticians, SALT, OT. There were mixed recordings of family involvement in reviewing of care plans. Some records evidenced involvement whilst others did not. Handover records were not used as intended. There was no evidence of how actions are followed up.

We received mixed feedback from people about feeling safe at Sowerby House. Comments included, “Safe? I never see any of them” and “I couldn’t manage at home and my wife was struggling as I’d had a stroke so I came here. The girls are really nice and help me."

Staff were able to discuss types of abuse and the required actions to report and investigate their concerns. However, there was a lack of awareness of associated policies and procedures to ensure correct procedure was always followed.

Staff and managers were all open and welcoming during the visits. People appeared to be comfortable living at the home, and in the company of staff supporting them. People told us their visitors were made welcome.

The provider had processes in place, but this was not always effective. 80% of staff had received training in safeguarding people from abuse. Monthly accident and incident report had been completed but management had not identified areas of concerns and where improvements could be made. The audits had not been shared with staff or people living at Sowerby House to ensure lessons were learnt. This meant people were not always protected from identified risks.

Feedback from people and their relatives was mixed in terms of the consistency and abilities of staff at the home. Comments included, “Some of them [staff] haven’t really got a clue but I’m patient with them” and “I am allowed to call the emergency call if my alarm bell isn’t answered in 20mins. Management agreed that I could do that as a bit of quality control when I complained about how long it was taking to respond".

Staff told us they routinely involved a range of professionals to support people.

We observed staff supporting a person to mobilise and walk using walking aids. They did this checking about their safety in a respectful, gentle way. However, we observed people waiting significant times for help when they had requested it.

The provider did not have an effective process to involve people to manage their risks. Risks to people were not assessed or managed safely. Care records were not always accurate or complete. They were not sufficiently detailed, personalised, or regularly reviewed. This included care plans and risk assessments relating to health conditions nutrition, mobility, falls, medication, continence and skin integrity. They did not provide sufficient guidance for staff to manage risks to people. Care plans and risk assessments did not demonstrate people were involved in managing risks. Risks to people were not always clearly documented in their care plans to ensure people's needs and risks were mitigated or managed safely. For example, one person’s care plan had conflicting information regarding their kidney care, support, and treatment. Another person's care plan stated they had diabetes. However, there were no person-centred guidance in place for staff to follow to support this person safely. There was little evidence people, or their families had been engaged with when planning their care or managing risk.

The layout of residents rooms were off either side of very narrow corridors, which had a 90degree turn at the end, effectively cutting off the view of these residents doors completely. Residents rooms were particularly bare and lacking in personal items. There is no security code for using the lift and its location was unobservable both up and downstairs.

The environment of the home was not always safe. Staff told us they were passionate about ensuring the safety of all residents but due to insufficient staffing to support these areas, standards had slipped. The registered manager discussed ongoing recruitment to manage these shortfalls. The area manager discussed processes that were in place to improve the environment. This included resourcing staff from other local services pending the recruitment of suitable employees.

We found areas of the home that required urgent maintenance and updating.

All required checks and maintenance to the buildings and equipment were mainly completed or current. However, a recent fire risk assessment had identified actions as high priority to be completed within 1 week, 1 month and 2 month. There was no evidence to support these actions had been completed. Window restrictor audits were recorded as a quarterly audit, however, these had not been complete since July 2023. Fire drills were completed monthly, however, no times were recorded to assess and inform decisions about safe evacuation times. When things were recorded as ‘what went wrong’, no action was pulled through.

Feedback from people and their relatives was mixed in terms of the consistency and abilities of staff at the home. Comments included, “Some of them [staff] haven’t really got a clue but I’m patient with them” and “I am allowed to call the emergency call if my alarm bell isn’t answered in 20mins. Management agreed that I could do that as a bit of quality control when I complained about how long it was taking to respond."

Some staff discussed how low staff impacted on their ability to carry out their roles effectively. For example to maintain environmental standards. Care staff told us they were able to meet people’s everyday needs but they emphasised how the service would benefit from additional permanent staff to ensure they could always provide people with the required support to meet their needs and expectations. The registered manager told us they routinely reviewed peoples needs and staff were adjusted accordingly. The use of agency was implemented to support full time staff and they confirmed recruitment was ongoing to provide people with consistent care and support from people they knew.

We observed calm and relaxed support during the visits. Staff were patient and attentive to people, and interactions were friendly.

Staff were not receiving regular 1:1 supervision. However, there had been some infrequent group supervisions around specific topics area’s. We recommend the provider reviews their systems to ensure staff receive regular supervision. Provider had a checklist for audit purposes, however, this was not always completed Staff were recruited safely. All required checks were made prior to staff starting to work at the home. Whilst rota's reviewed mostly reflected staffing levels highlighted on dependency tool, we could not be sure that the dependency tool was an accurate reflection of people's current needs. The registered manager said they would review to check the accuracy. There were systems in place to enable the provider to identify staff’s equality, diversity or inclusion needs. Sowerby House had won an award at a ceremony held by the provider for work around raising awareness of other cultures.

People and relatives we spoke with raised concerns with the cleanliness of the home. One person told us, “It’s dropping to bits. I can’t remember when this room was cleaned last. I keep asking if someone can just vacuum round but I’m still waiting. Last time I had a shower in my bathroom the carers asked me to ask for it to be cleaned. I did and someone came up and looked but went away and hasn’t been back."

People were at risk of poor health because the service did not always have enough staff to maintain infection prevention and control activities in line with required standards. Areas of the home were not always clean or well maintained. Staff told us they were not always clear on policy and procedural requirements or where these documents were and they raised their concerns that there were insufficient staff to maintain the home to the standards required.

People were at risk of poor health because the service did not always have enough staff to maintain infection prevention and control activities in line with required standards. We observed people’s rooms were not always clean and some had noticeable unpleasant odours. Service rooms, including the laundry were not clean and were observed to be disorganised without the appropriate separation of laundry. For example, soiled sheets were in piles with non-soiled laundry. We found areas of the home that required urgent maintenance and updating to reduce the risks associated with cross infection. For example, where some people required support to manage their continence, associated room repairs had not been completed in timescales appropriate to the identified risks. Several rooms required updating which included replacement bedding, flooring, storage and decoration.

During our onsite visit, we identified concerns in relation to infection prevention control (IPC). This placed people at risk of injury or infection. We found that not all areas within the service were maintained to a high standard, for example scuffed walls and doors, worn carpets and stains on walls, bed linen and ceilings. This placed people at risks such as infection as they did not allow for effective cleaning. Cleaning records were inconsistently complete and there was no IPC lead within the service. We were not assured the provider was making sure infection outbreaks can be effectively prevented or managed. The provider had failed to act on previous infection control audits to reduce the risk of transmission.

People did not raise any concerns about their medicines with us. However, people’s medicines were not always given in the way prescribed for them. People did not always have medicines care plans to help identify and support their needs.

Staff told us they had received medicines training and had a competency check.

We found ongoing concerns with medicines management and administration. Systems in place had failed to ensure the proper and safe management of medicines. Medicines were not always available at the home meaning people had missed doses. Where medicines were available some people had missing administration signatures and stock counts indicated these medicines had not been administered. Medicines administration records (MARs) were not always accurate. For example, transcribed medicines were counter signed as accurate when errors had been made. Records did not indicate the dose administered for variable dose medicines. Records to guide staff in supporting people with their medicines for example as required medicines protocols or variable medicines guidance or medicines care plans were either missing or lacked person centred information. One person was prescribed an antibiotic, however, this had not been administered as prescribed. We asked for this person to be reviewed. Some people were prescribed medicines for agitation and anxiety. No as required medicines protocols were in place to support carers to safely administer these medicines. Care plans were not person centred and lacked detail on de-escalation techniques. Where medicines had been administered in most cases no outcome was recorded and no incident forms had been completed. Medicines within the treatment room were stored securely, however, we found 2 loose tablets, 1 in the treatment room, 1 in a person’s room. Some dates of opening were missing from medicines. Temperature monitoring was not consistently recorded for room or fridges to ensure medicines were fit for use. Internal and external medicines audits had been completed with actions being documented, however, these actions had not been acted upon.