Jigsaw Creative Care limited

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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

We observed risks being managed well with supporting risk assessments and guidance in place for staff. Staff knew about the process for recording and reporting incidents. However, some relatives were concerned about how risks were managed and professionals gave us examples of risks being overly managed so people were restricted, impacting on freedom of choice. This is not in line with the principles of Right Support, right care, right culture which expects people to have maximum choice and control . Some policies and procedures that staff referred to had been reviewed recently but still contained inaccuracies. Staff were trained and knew people well and there were enough staff to meet people’s needs. People’s money and property had not always been safeguarded. The provider’s audits had picked up some discrepancies. There were some ongoing safeguarding investigations being led by the local authority which the provider was cooperating with. Medicines were managed safely.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We observed people were relaxed in the company of staff and each other. Risks were being managed subtlety and respectfully, for example, one person’s home environment was adjusted to help them relax when they returned from an activity. A staff member told us, “We have learned that this helps (person) to relax when they return home from activities, because they are occasionally agitated. We re-adjust the lighting when we are clear (person) is more chilled.” A relative told us they were concerned about an increase in their loved one’s self-injurious behaviour. They felt more activities and fewer staff changes might help reduce the number of incidents. In response, the registered manager said they were offering more external activities as well as offering activities in house.

Staff we spoke with were aware the provider had an incident reporting policy. Staff told us about the process for recording and reporting incidents and said they reported to their managers. There was a dedicated incident reporting inbox which was monitored regularly throughout the day by senior staff. One told us, “The process following an incident includes a discussion with (senior manager) to identify what could have been done differently and to learn from that. Sometimes things happen anyway, even when we are exactly following the personal behaviour support plan.” A senior staff member told us, “Each incident is considered on its own merit. Part of our reporting is about our learning. From the reports we can pick up on what might have been left out and whether personal behaviour support plan was followed. It may cause us to consider reviewing their risk assessment.” A registered manager told us how the provider used incident reports to identify themes and any actions needed in response to events. The registered manager said, "We look at whether a behaviour is happening more often than it used to, any emerging themes. If it is a behavioural incident, we look at PBS - have they implemented the PBS plan? Do we need to tweak the PSB plan? We look at the antecedents - were there any triggers? Is there a training need? We may need to go back to the service manager."

Visiting professionals gave us examples of some safety events that had been recorded in people’s daily notes rather than on the electronic system. Some of these events had not been tracked or reported appropriately so follow up action and learning could happen. The provider said they would address this. A health care professional told us for one person, 'Incidents were reviewed regularly and ‘any advice and guidance was well received’. Another healthcare professional said incident forms ‘have been detailed accounts and reflections from both the staff team involved in the incidents and the management’. Other comments included ‘They inform us of any issues in a timely manner and report safeguarding incidents,’ and ‘I believe the provider learns from incidents. When I reviewed some people’s incident forms there have been detailed accounts and reflections from both the staff team involved in the incidents and the management.’

The provider had a process for staff to report safety incidents. Incidents were tracked on an electronic system to help identify patterns or trends. Incident reports we reviewed were completed and dated and had been reported appropriately. Incident reports included detail regarding the management of the incident, as well as actions taken and any interventions employed, including guidance from senior members of staff where requested. Staff had clinical supervision with an independent health care professional.

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.

There had been some safeguarding issues raised by people, social workers and staff. These were being investigated by the local authority safeguarding team. Some people used some of their income to fund a car, driven by staff. Mileage records for one car were not up to date so it was not clear to the provider who had used the car, when and to go where. The operations manager said this would be addressed. Discrepancies had been found by the provider's audits in some people’s finance records which was being investigated. The provider had commissioned a third-party company to receive any whistle-blowing concerns staff wished to raise anonymously. The provider told us this arrangement had been made to ensure staff felt able to speak up without fear of recrimination or reprisal.

Staff we spoke with were aware of the signs of abuse and knew who to report to. The provider and registered managers were aware of their role and responsibilities in safeguarding people. One told us, “Safeguarding is about protecting the people we support from abuse, harm and neglect. I would raise concerns with my line manager, document the episode and report to the manager who then processes it to the local authority and CQC.”

We observed people were relaxed in the company of each other and staff. We saw evidence that staff had supported people to report incidents to relevant authorities when necessary. For example, staff had supported one person to report an incident to the police. We met some people in their homes, they appeared calm and were engaged in activities of their choice.

Systems to protect people’s money and property needed strengthening. The provider had a policy relating to people’s money which stated, ‘Each journey done in the car for the person we support must be documented in their mileage logbook, this must record every journey done in the vehicle. Managers must check this is being recorded’. We saw in one logbook this was not the case, staff had not documented every journey. Feedback from professionals was mixed. Social care professionals told us they had requested some policies including the safeguarding policy. They found some policies were not up to date and some had omissions. The provider said they have reviewed and updated policies since then. Healthcare professionals told us, “Jigsaw staff recognise safeguarding concerns and these are discussed openly during our 6 weekly visits with the individual we are supporting,” and “Jigsaw raised safeguarding concerns of self-neglect regarding a person and also liaised with us on several other occasions regarding safeguarding concerns for people.”

We observed people taking part in everyday activities, staff were managing risks well. A family member told us “Staff definitely understand any potential risks, there are reams of information about (person).” Another relative said “I was part of the planning when they moved in” and “I have a very collaborative relationship with staff.” A relative said they were worried out how risks were being managed and were trying to engage with the provider for more information. The provider informed us they had sent this information to the person’s social worker.

Positive behaviour support plans were in place which included detailed guidance for staff on how to support a person when they displayed extreme anxiety or behaviours which challenged staff. If people were subject to any physical intervention this was assessed and recorded and kept under review. When physical interventions were needed, staff said they used the least restrictive option to keep people safe. Staff were trained in physical interventions and if needed, specialist support was obtained to help plan the support interventions used by staff. Staff knew people well and we observed staff managed one person’s anxiety by sequencing their day in a sensitive way. Staff noticed when people wanted privacy and space and respected this. Staff spoke with awareness and knowledge about risk and the need to promote positive risk taking. They could describe in detail how they managed people’s risks in line with their individual positive behaviour support plans. A member of staff told us about one intervention and said, “This is a good intervention for (person) If something triggers a behaviour this helps them organise their thoughts.” Another staff member told us, “We encourage people to go out. We like to do new things, but first we risk assess the new environment. When we consider a holiday, we visit and assess all the risks.”

We observed some gentle interactions by staff to enable a person to do as much for themselves as possible without restricting them. One person showed us what they had prepared for their evening meal with staff support and told us, “I like living here, staff are kind and look after me.”

Risks were identified, assessed and managed with guidance for staff set out in positive behaviour support plans. Professionals told us there was not always a balanced proportionate approach to managing risks. For example, the practice of recording and photographing what people ate in an over cautious way, which could infringe people’s rights. Professionals told us another restriction, the use of ‘Ring' doorbells, had been imposed that had not been assessed as necessary and as the least restrictive option available. People had not been asked for their agreement. The provider was addressing this retrospectively The provider had policies and procedures to safeguard people including a policy on the use of restrictive physical intervention (RPI). Although the policy had been reviewed and dated May 2024 the policy was not up to date. It referred to the names of 2 RPI trainers who no longer worked for the provider so staff did not have up to date information to refer to.

A relative said their loved one’s home was not always clean, they said bedding and towels were not changed often enough. In response, the provider told us about their system for checking staff were supporting people to keep their homes and property clean and safe. The properties we visited appeared clean and well maintained. One person said “The home is clean and well maintained, the kitchen and bathroom are spotless.” We observed that equipment and adaptations were in place for people who needed them, such as ceiling track hoists, adjustable beds, and adapted baths.

The daily handover document included allocation of responsibility for general oversight of cleaning and infection prevention and control to individual members of staff. Staff we spoke with were aware of their allocated shift responsibilities. Risk assessments were in place to identify any risks to people in their home environment, such as using a hoist for transfers, using the shower, and using the kitchen. Health and safety audits of each supported living property were carried out regularly and a fire drill was carried out each month. A personal emergency evacuation plan had been developed for each person, which detailed the support they would need in the event of an emergency.

A service user told us, “Staff respect me and listen to what I want.” One relative we spoke with said they were given information about what staff were on call so they knew who to contact, which they appreciated. Most relatives we spoke with said there were enough staff and they thought staff were well trained. One relative said there needed to be better communication between leaders and staff. In response, the registered manager said, ‘We use communication books in services and also use online communication tools such as Signal for effective communication between staff and managers. All families have the contact details for managers and senior staff associated with their loved one’s service’. Another relative said, “Staff definitely understand (person’s) needs and triggers. One of the most important things is continuity and there has been regular staff for many years.” Healthcare professionals told us they thought staff had the skills needed to meet some people’s quite complex needs. One said ‘I have observed staff interacting with residents in a manner that is respectful and kind as well as understanding of their needs’. Others said, “Jigsaw support some people with very complex needs and in some cases extreme behaviours which may be challenging, requiring a high level of competence, skill and training. In at least one case, I believe the person would be back in hospital or placed out of area if it wasn’t for the service Jigsaw provide,” and, ‘Yes, staff are trained and have the skills and knowledge to support people. This is essential as they are supporting some very challenging individuals whom without the support and commitment of Jigsaw are likely to be placed in secure services or out of county.’

Staff told us they had a comprehensive induction when they joined the organisation, which included shadowing experienced colleagues to understand people’s needs and how they preferred to be supported. All staff had a probationary period when they joined the service. A probation review took place after six months, at which point a decision was made whether to sign the member of staff off as competent, or to extend their probation if they needed further support. One of the registered managers led on staff training. They told us staff completed a 12 week induction of mandatory training as well as completing the Care Certificate. We were also told, “We put a lot of emphasis on continuously training, which includes NVQ, Care Certificate and Grey matter training. Where a person comes to us with a new condition, we liaise with the healthcare professionals who will support us with required learning.” Staff were trained in supporting people with learning disabilities and or Autism. This included Positive Behaviour Support and restrictive physical intervention. In addition to mandatory training, service-specific training was provided according to people’s individual needs, including diabetes, insulin administration, and epilepsy. The provider used an electronic system to track staff training which showed a current compliance rate of 86%. Staff told us they did a mix of face to face and online training. They said they had regular supervision meetings with a manager to talk about their development. One told us, “I have regular supervision, it helps me to improve how I communicate with the staff; I see supervision as a positive experience, it has definitely helped me a lot.”

We observed people had the support they needed when they needed it. We observed staff supporting people in a calm respectful way at each of the locations we visited. Staff knew people well. People took part in a range of activities and some told us they were busy. Staffing was tailored to each person’s needs and funding arrangements. People participated in activities according to their individual interests, such as horse-riding, bowling, going to the cinema, and attending day centres and colleges. One person told us about being supported to attend a family event abroad and others told us about their individual holidays.

People had dedicated hours of staff support. Staffing rotas were planned centrally taking into account the hours of support people needed. People had allocated one-to-one support hours which were used flexibly to enable people to take part in activities of their choice. There was an on-call rota that senior staff took part in. This was planned so staff had plenty of notice and ensured staff could seek advice out of hours when needed. Staff also took part in a rota so they could be called on to cover short notice leave. This reduced the need to employ temporary staff from an agency so enabling consistency for people. There was an out of hours rota which senior staff took part in and which staff were aware of and knew who to call in an emergency. We reviewed the provider’s supervision and recruitment policies which had been recently updated. Staff we spoke with told us about the supervision process which included being observed by a senior staff. One staff member gave an example of how they had developed from this process. We sampled 4 staff recruitment files; all contained the relevant checks to show safe recruitment practice.

Cleaning schedules were in place to ensure all areas of people’s homes were cleaned regularly. Staff attended training in infection prevention and control (IPC) and understood how to protect people from the risk of infection. Staff supported people to keep their homes clean. The supported living properties we visited were clean and hygienic. A relative said their loved one’s home was not always as clean as it should be. In response, one of the registered managers told us, “We monitor cleanliness via audits, spot checks and general communication. On the ‘Log my care’ platform we would record if the person being supported has completed laundry or changed bedding etc.”

People were supported to take their medicines safely. Medicines were stored safely and people were supported to have as much control as possible. A relative told us, “I have no concerns about medication and staff have worked collaboratively with us to advocate for lower doses.” Another relative said, “Staff complete medicine record sheets and when (person) comes home we are given a copy to record their meds.” People’s medicines were reviewed by a GP at least annually which reduced the potential for the over-medication.

A senior member of staff told us, “Each house has its own process for ordering medicines. Each person has a medicines cabinet in their room.” A staff member talked with knowledge about the medicines system and said, “When medication is delivered, I make sure everything is correct before I book it in. My medicines competency is regularly checked.” A service manager told us that, if a member of staff made a medicines error, "We remove them from doing meds and we retrain them. We have to make sure the person is competent and confident."

We observed staff administered medicines competently and safely. People’s medicines were stored in a locked cabinet in their room.

Medicine administration records (MARs) were audited at each service every week by a service manager. These audits were submitted to the quality inbox and reviewed by operations manager and the provider so any issues could be picked up. Staff attended medicines training and their competency in medicines management was assessed four times a year. There were appropriate arrangements for the ordering, storage, disposal, and administration of medicines. Medicines stocks in each supported living property were checked and recorded twice each day. All the medicines we checked were in date and had the date of opening recorded. The medicines administration records we checked were accurate and up to date. There were individual protocols in place for medicines prescribed ‘as required’ (PRN). Any PRN medicines administered were recorded on people’s medicines administration records, including the reason for administration.