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• 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

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff were able to identify changes in behaviours and presentation when people were feeling anxious, upset or concerned about something and act accordingly. Lessons were learned when things went wrong. There were processes in place to ensure that people received medicines safely. However, where medicines were given covertly (hidden in food or drink) at the service the process of completing a best interest decision meeting wasn’t being followed robustly. Staff were recruited safely and were supported through training, there was a plan in place to make sure they had ongoing support in the form of supervision and appraisal meetings. There were enough staff to support people safely. Ongoing training made sure that staff had the skills needed to support people. Accidents and incidents were reviewed and actioned by the management team.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were safe and were protected from harm. A relative told us they were “I feel that my husband is safe here some of the staff have gone above and beyond to get to know what he needs.” Staff were attentive to people’s needs and made sure they were safe as they carried out their daily routines. Relatives told us they were confident to raise any concerns and knew that they would be responded to. A relative said, “The manager is very approachable.”

Staff had received adult and children’s safeguarding training and had yearly refreshers. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member gave the example that if they did something which was not right, if they reported it immediately, they would get support to learn to do things in a different way, but if they did not report something they did wrong they knew there would be more serious consequences. There had been numerous safeguarding concerns at the service due to the nature of the people who lived at the service who at times had become agitated by one another. This was physical or verbal aggression. Staff knew to report all incidents on an incident form and these were reviewed by the manager. There was a safeguarding tracker which recorded all safeguarding reported to the local authority together with any actions they needed to take.

We observed many interactions between staff and people during our visit, which helped to keep people safe. We saw safe practice whilst allowing people to maintain their routines and come and go around the service as they wanted. A person was starting to sit on a chair where another person was already sat, so they were about to sit on other person’s lap. Staff very gently guided the person to sit on a chair next to the other person. The staff member then supported the other person to move out of the way because the person was starting to get annoyed. This was all achieved very calmly and with respect to both people.

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff knew how to whistle blow. The management evidenced that actions had been taken and appropriate referrals and contacts made appropriately. The management team told us they had positive working relationships with the local authority and other statutory partners and were confident to seek advice and report safeguarding issues in a timely way. There were processes to monitor, report and escalate concerns about people’s safety. The management team had escalated concerns about the safety of people and staff as a result of a person’s anxieties. They had put in 1:1 staffing to keep people safe before funding was agreed by the local authority.

Relatives told us they were informed of risks and concerns and had access to view records through a relative’s gateway. People used equipment to keep them safe. A relative told us that staff picked up on changes to their loved one’s behaviours and presentation and knew them well. They said, “They have got to know her very well although she does not speak, they can tell what she wants from her bodily gestures.” Another relative said, “They call me every time if he has fallen or if he has had any physical altercation with another resident”.

Most staff knew people well and were confident they could identify any changes in people’s presentation that may be of concern. Some members of staff did not know people and risks associated with their care despite this being clearly recorded in people’s care plans and risk assessments. A person had been assessed at risk of self harm through suicide. Their care plan made these risks clear and evidenced that the person should not have access to belts or cords, razors or other sharp objects. Staff were not aware of the risks to the person.

We observed that some risks were not always well managed. We checked the person’s room who had been assessed at risk of self harm, they had a corded call bell and other electrical cords in the room. This put them at risk of harm. We observed staff following risks assessments, which described triggers for people’s anxieties and behaviours. We saw staff putting this knowledge effectively into practice, supporting people to calm when they became agitated.

Risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. We identified some concerns with falls management. A person had fallen 8 times since January and no referral had been made to the falls team, following good practice guidance. Falls assessments, care plans and risk assessments did not include that the person was prescribed a blood thinning medicine which increased their risks of internal (unseen) injuries, bruising and bleeding if they fell. We discussed this with the manager and they advised they would make a referral to the falls team and stated they would amend the risk assessments and care plans to make it clear to staff the safe ways of working.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People benefitted from being supported by staff who understood their roles and responsibilities and genuinely cared for their wellbeing. People had access to staff in a timely way as there were staff situated in the lounge and corridors. Staff conferred with one another to ensure staff were available where they were needed. Relatives told us that staff were kind. Relatives said, “The staff are so kind to him and to me. They know him really well. They are brilliant, they take everything in their stride. Even the agency nurses all know him, agency staff are regular.” Another relative told us, “Staff recognise his challenges and he is treated with respect.”

Staff told they had received the training and support they needed for their role and there were opportunities for development. Staff were clear about their roles and responsibilities. A number of roles had been created so staff were able to be promoted. Quality leads buddied new staff and gave them ongoing support and also carried out audits and observations and staff supervisions. They had undertaken additional training for this role and there was more to come which they were looking forward to. All staff said how wonderful the manager was. They were open and they listened. Staff told us the deputy manager was a great support as their office was on the top floor where people with the most anxieties were. They explained the deputy manager would come on the floor and help out when needed which was much appreciated. Staff said they worked in a great team and were supported by colleagues. They said there were enough staff, although it did vary sometimes. All staff would recommend working at the service. Overseas staff had been separated from their families to come and work at the home. They said this was very much taken into consideration by the staff and management which helped them to settle in their role and give their best to people receiving care and support.

We observed there were enough staff on duty to support people. Staff were responsive to people’s needs. Staff took time to chat with people and interact, this included non care staff such as housekeeping.

Staff had been safely recruited. We examined 3 staff files and all of the required checks had been carried out and documents were all in date. In files we saw copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. A dependency tool was in place. The management team took information from the care planning software and exported it to a spreadsheet to calculate a dependency score. This told the provider and management team how many staff are needed and what skill levels are required to meet the needs of the people using the service. The information was updated monthly to take account of any changes or new admissions to the service. The provider had effective systems in place to ensure that staff had adequate induction, training, support and supervision.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People mostly received their medicines safely. Relatives told us, “Dad gets his medication on time” and “We have had no issues with his medication here he does have quite a lot in liquid form as he can have problems taking it.” Some people on time sensitive medicines such as those to manage Parkinson’s disease were not always having these given at even intervals throughout the day. Failure to give certain medicines such as those prescribed for Parkinson’s disease outside of the prescribed timings can lead to a deterioration in the condition. There was no specific procedure in place to ensure that these medicines were always given at the correct time each day and that there was a robust oversight process.

People received their medicines from trained staff. The staff who were responsible for administering medicines told us they had received training. We saw that staff from the service would complete the documents within the service without having a multidisciplinary team (MDT) discussion. They then sent off the completed form for sign off by the GP and pharmacy which meant there wasn’t a proper peer discussion taking place. We also found that sometimes covert administration would be requested and authorised not due to lack of compliance and capacity but due to swallowing difficulties. This showed staff did not fully understand the covert administration process or have adequate challenge to the decision to use this restrictive intervention. The GP did not attend onsite and so was not able to assess or review the need for covert administration routinely. This was sometimes taking place annually rather than the recommendation from the provider that it be done every 6 months. There was not sufficient oversight of covert administration taking place at the service. There was low use of PRN medicines to manage anxiety and agitation in the service. Staff were aware of different techniques including distraction and de-escalation which helped them avoid the need to use medicines to control behaviour. Care plans were in place which supported staff with the process to follow if someone was showing signs of anxiety and agitation, these didn’t always have specific details relevant to the individual. However, it did ensure the use of medicines would only be seen as a last resort if all other methods had been unsuccessful.

There were processes in place to ensure that people received medicines safely. This was supported by an electronic medicines administration record (e-MAR). However, where medicines were given covertly (hidden in food or drink) at the service the process of completing a best interest decision meeting wasn’t being followed robustly. This meant there was no adequate challenge to ensure that the decision to administer a medicine covertly was being made in a person’s best interest. Medicines that needed to be given at set times each day weren’t always being given in a timely manner. This could impact on how well a person’s condition was managed. The service used an electronic medicines administration system (e-MAR) to record regular and ‘when required’ (PRN) medicines administration. Staff had access to handheld devices which provided all the information required to ensure that medicines were administered safely including PRN protocols. This supported staff to understand how and when to administer these medicines safely and effectively. The e-MAR provided an additional level of safety that staff had to scan the bar code of medicines to ensure they were giving the right medicine to the right person. Discrepancies could then be prevented before the staff member went to administer to the person. Where medicines were prescribed for covert administration, there wasn’t always clear guidance in the instructions for the medicines as to which were suitable to be given covertly and how this was to be done.