Pytchley Court Nursing 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 means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Lessons were always learnt to continually identify and embed good practice. A relative told us, “They always communicate with me right away. For example, [Name] had a fall in February and I was fully involved in discussing the circumstances and prevention measures then put in place, there was no history or apparent risk beforehand.”

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. Staff advocated for people when they went into hospital to ensure they received their ongoing planned care whilst waiting to be assessed by health professionals. For example, this ensured people living with diabetes were kept safe. A relative told us, “The transfer was from another HC-One home and was well handled at both ends. We were able to look at other alternatives as well. The existing care plan was sent through and assessed as still appropriate.” People’s hospital passports were detailed and up to date; they included how people communicated to show they were in pain.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately. Feedback from the local authority safeguarding team included, “From the start [registered manager] was very open and transparent and we worked together to try and establish what had happened; she is not afraid to challenge or have a difficult conversation if it means a better outcome for her residents.” The registered manager often checked the service at different times of the day and night to ensure that people were safe; where they had identified issues, these were investigated and acted upon immediately. Accidents and incidents were recorded in detail and people’s health and well-being were closely monitored afterwards. Information about the learning from incidents was shared with staff to help improve people’s safety.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. A person said, “I do believe I am involved in everything about me and my care, they do come and speak with me about what I would like to do or how I feel about this and that.” A relative told us, “[Name] has very fragile skin and occasional skin tears. There is a risk assessment for that, and I see they look after [Name] very well. Yesterday they rang because [Name] was ‘resident of the day’, that seems to be how they review the care plan and is a good way of keeping me involved and making sure everything is up to date.”

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People were kept safe through regular checks and maintenance of the home and by following safe fire and water procedures. A relative said, “Internal doors have security codes to keep people safe; visitors are given the codes, but access to the home itself is controlled.” The garden had been improved to make it accessible. A relative told us, “The gardens were fully used during the summer months, including by us.”

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. People’s dependency was calculated regularly to ensure there were enough staff to meet their needs. A person told us, “I would say that there are plenty of staff, I never wait and they come and help me in time. There is always somebody around to help.” A relative said, “I come here every day and to me there is always plenty of staff and carers and they all work around people offering drinks, making sure they are safe in chairs.” All staff received training in mental health first aid. All staff had completed the care certificate and most had undertaken vocational study such as a diploma or NVQ in health and social care.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff were trained to detect and manage infections by monitoring people with catheters or wounds for signs of infection. Where people were on antibiotics these were monitored for their effectiveness and staff referred people back to the GP if their condition was not improving. The weekly clinical review included monitoring the infection control audit and competencies check. A person told us, “I like my room, it’s very clean, carers keep it clean for me.”

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. A relative told us, “I’ve been kept well informed, such as whenever there has been any change of medication.” Staff had received training in the safe management of medicines and had access to information they needed about particular medicines, for example, how to apply patches safely. The clinical pharmacist told us, “The nursing staff/care staff and management team are always available and provide good insights into how the patients are doing not only related to their medication and health but also their well-being.”