59 Bury Road

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

During our assessment of this key question, we found systems and processes in place to safeguard people from abuse were not always effective. Some people in the service could become anxious and their behaviour could put themselves and others at risk. The provider had failed to assess a restrictive practice in the service to determine whether it was necessary and proportionate in relation to the risk of harm, placing service users at risk of excessive supervision and institutional abuse. This was a breach of regulations 13 Safeguarding service users from abuse and improper treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found concerns around people’s risk management and the provider had failed to ensure potential risks were assessed and mitigated. This was a continued breach of regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.Not all staff were complaint with the required training and recruitment practices needed to be improved to keep people safe. This was a breach of regulation 19 Fit and proper persons employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager was able to confidently describe how they learnt from complaints, safety related concerns or near misses. She talked about debriefs, having conversations with staff and people and putting actions in place to prevent recurrence. Two staff members told us they were encouraged to raise concerns, one told us the manager was, “Usually pretty supportive.” Staff felt there was a culture of safety within the service however, stated it was compromised due to the mix of people living in the service. One staff member felt they received reassurance following an incident rather than feedback. Another staff member also stated they do not receive feedback following an incident. A third staff member told us feedback and learning were “sometimes” shared. We could not be assured that lessons learned from managers reviewing incidents were always shared with the whole team in order to support learning and improvement.

People we spoke with were not able to tell us if learning had taken place following an incident. One relative felt they did not always report every behaviour incident to them. But felt if it was a more serious incident they were kept up to date.

We reviewed incident forms during the site visit and we saw evidence that the duty of candour had been met. We saw behavioural incidents being reported daily. The process on the provider’s system was for the manager to review incidents with the provider through their electronic incident reporting system. Incidents could not be closed on the system until the manager had reviewed them and updated any actions or lessons learnt to be shared with staff to prevent reoccurrence. Most of the incidents we reviewed had not been reviewed by the manager. The manager was able to show us, the function within the incident form to take learning from incidents, however, was unable to show any recent incidents where this had been completed. Therefore, we were not assured learning and improving following incidents had taken place to reduce the risk of incidents occurring.

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 did not always feel safe living in the home due to the complexities of some of the people being supported at the home. One person told us, “I don’t feel safe when I am downstairs. I do feel safe in my bedroom.” Relatives felt their loved ones were safe. One relative said, “I do feel that the service is safe and I believe that my relative is looked after to the best of the staff’s ability.”

Some people received regular checks to ensure they remained safe. However, the provider had failed to act in accordance with the Mental Capacity Act 2005 and the code of practice on deprivation of liberty safeguards when imposing routine checks and restrictions on people. Records did not show how these decisions had been made when people lacked capacity to agree to checks and restrictions. People’s Behaviour Support Plans had not been reviewed since 2019 to ensure support strategies remained effective. Training records showed not all staff had received appropriate Positive Behaviour Support. There was not always a suitable staff member on shift with the appropriate training. We reviewed the safeguarding tracker. We saw evidence of safeguarding concerns being reported to the local authority and CQC. The training matrix we reviewed showed that not all staff were in date for safeguarding training.

Staff felt there was a culture of promoting safety within the service and could explain how they supported people when they became anxious to remain safe. However they told us people’s behaviour strategies were not always effective. Staff told us not all staff had received training in how to support people when they became anxious and agitated. They felt scared at times and said one staff member had been injured when supporting a person as they had not had the relevant training. The manager told us they always ensured 1 Positive Behaviour Support trained staff member was on duty and it was their responsibility to support a service user if they experienced a heightened state of anxiety. However, staff told us this was not always sufficient if more than one person became anxious at the same time. The manager told us following our feedback, they would take action to ensure people were safe and their rights protected. Staff were able to describe the signs of abuse to look out for and all staff felt confident the new manager would react appropriately to any safeguarding concerns. The manager was able to discuss safeguarding, the process for reporting to the local safeguarding authority and CQC. They told us they discussed safeguarding at their first team meeting and this will be an ongoing topic. The manager told us they supported people to raise any safeguarding concerns by observing them, listening to them and told us they have an easy read ‘How to raise a Complaint’ document.

During the onsite inspection we heard one person banging from the bathroom, we were told by staff the person likes to bang the side of the bath and this does not mean the person is in distress. They told us, they recognise the difference between the noises of being settled and being agitated. Therefore, the staff on duty listened to people expressing their feelings and were skilled in understanding when someone was in distress.

Although risk assessments were in place for some risks, they did not always contain enough information to guide staff on how to mitigate and manage the risks relating to people’s needs. One person’s care plan identified they were at risk of choking due to a medical condition; however there was no speech and language therapy (SaLT) assessment in place. However, the manager told us they had been seen by SaLT. There was a risk management plan in place and staff knew to support them at mealtimes. This person had a medical condition; however, there was no risk management plan in place to describe to staff how this affected the person (other than choking) and the signs to look out for if they were to deteriorate. For another person their support plan guided staff to restrict the persons fluids due to constant drinking; however, the plan did not detail how much fluid they could have.

Staff told us some plans and risk assessments needed to be updated. All staff gave us examples of how they might mitigate risk. Staff described how they would support people to remain safe whilst eating and when they became distressed. Some staff told us that they did not feel that strategies to support people when they became anxious was always effective and that they at times felt scared. The manager told us they were aware that some action was needed to update people's risk assessments however they had only been in post for 4 weeks and have not had the opportunity to complete this work at the time of our assessment.

During our first on-site visit, we observed one positive observation where a person at risk of choking was supported to eat safely. However, we observed another person was not supported adequately to ensure their soup was of a safe temperature. The manager took action to cool the soup when we informed them of our concerns.

People and their relatives were happy with the support provided. People we spoke to, told us they would talk to staff if they had a concern and they felt listened too.

All maintenance records were checked during the on-site visit, and we found all safety certificates were in date and equipment was maintained correctly. We reviewed the fire file and could see that actions had been reviewed and completed from the fire risk assessment. However, fire drills were not always taken place as needed and there were gaps in the daily checks for January 2024. We spoke to the manager about this who told us, they would address this with staff.

We looked at people's home environment. There was dust in some people's rooms. One person’s bathroom sink was unclean and their ceiling looked damaged by a leak. The area manager confirmed there had been a leak above the bedroom which has been repaired. However, the person’s ceiling had not been repainted. The area manager said they would report it to the maintenance department. Although people’s bedrooms would benefit from some cleaning, the communal areas were clean and in good order.

The manager told us they do daily, weekly and monthly fire checks. They said everyone had a responsibility to raise any health and safety concerns. They told us some staff had completed fire Marshall training last week and staff's supervisions were used to follow up on staff training completion. The manager had identified improvements were needed to ensure people could be safely evacuated and was working towards all staff attending fire drills and fire training.

People raised no concerns about the environment. One relative told us they had checked their room and it had been redecorated recently and they were able to choose the colour of their room. Another relative felt their loved one's environment was safe and had been able to change rooms when they had concerns.

We could not be assured the service was following safe recruitment practices. We reviewed recruitment files for the 4 most recently recruited staff members. We found the provider had failed to always undertake checks to assure themselves of staff’s satisfactory conduct in previous employment prior to offering employment. This was the case for 2 of the 4 files we looked at. The provider was unable to show us any supervisions or appraisal’s the previous manager had undertaken. We saw supervisions undertaken by the new manager who began working at 59 Bury Road, in the mid December 2023. We were not assured prior to the new manager starting, supervisions/appraisals were being undertaken. Records showed that training was not compliant for example, safeguarding, moving and handling, infection control, fire awareness, medication, PBS. Therefore, we were not assured all staff are suitably trained to undertake their role. However, the manager was working towards ensuring staff were suitably trained and told us she ensured there were always competent staff on each shift.

People reported that overall, there were usually enough staff. One person told us, there were enough staff but sometimes there were too many agency staff. They told us, “I don’t like agency staff because they don’t know how to support me.” Another person told us, sometimes there are and sometimes there are not enough staff. They told us, “If there is enough staff in, I can go out, if not, I can go out the next day.” A relative expressed a real unhappiness with the turnover of staff and low staffing levels as they were concerned that this was beginning to impact their relative's mental and emotional well-being. We were not always assured from what people and their relatives told us there were always enough staff on duty to ensure people’s needs were met.

During the onsite visit there were enough staff on duty to support people with their needs. People appeared to be in receipt of their 1:1 support and we observed positive interactions between people and staff.

Most of the staff we spoke with felt there was not always enough experienced staff on duty. Staff told us if there is not enough staff on shift people were not always able to able to go out as much as they liked. Inductions for new staff had not been taking place prior to the new manager starting. We found 3 members of staff did not have induction paperwork in place. The manager was able to talk through the correct process for inducting new staff. Over the last year staff had not received regular supervisions and team meetings. The new manager had booked these in for staff and 2 staff told us they have had recent supervision and it was meaningful and helped identify additional training they needed. The manager told us how they spot checked staff and observed them to ensure safe practice was being carried out. They told us they ensured they had a fire marshal, a medication trained and a positive behaviour support (PBS) trained member of staff on each shift. The manager was able to describe their recruitment process in line with their policy. Although the manager was not aware that staff who had previously worked in health and social care roles should have checks undertaken to ensure themselves of the staff members previous conduct before commencing employment.

We were assured that the manager understood their responsibilities around infection prevention and control (IPC). The manager told us, “We do have a cleaning schedule and is part of the shift planner. I put a different one in place for morning, afternoon evening and night shift. Different days for people we support to deep clean their rooms.” They were able to confidently describe the process if an infectious disease was to enter the home. We noted the home was generally clean except for some sinks in people’s bedrooms.

We were assured that the provider was preventing visitors from catching and spreading infections. The provider’s infection prevention and control policy was up to date. People living at the service was supported to minimise the spread of infection and staff were using personal protective equipment (PPE) effectively and safely.

We reviewed medicines processes. We found 2 gaps in people’s Medicine Administration Records where staff had not recorded that they had administered paracetamol at nighttime. We spoke to manager who said they would address this with staff. When asked why this shortfall had not been picked up, the manager said they had not yet completed a medicine audit, but it was on their list to do and they would be conducting these weekly. When people had refused their medicines staff recorded this and the action they took. Medicines that required additional control measures were stored appropriately and recorded correctly.

People were happy with their medicine support. People told us staff listened to how they preferred to receive their medicines for example, in a pot or directly in their hand. When asked if they could request medicines when they were in pain, one person told us “Yes, I ask for tablets and they [staff] give them to me.” We observed this during our on-site visit. When asked if they receive their medicine on time, one person told us, “Sometimes they are late.” Another person told us, “Yes. 8am and 8pm.” During our on-site visit we observed 2 people being given their medicines. People’s needs were considered, and their medicine protocols were followed.

Staff were able to correctly describe how to administer medicines in line with the provider’s policy. However, only 2 out of the 4 staff were able to tell us that some people were prescribed flammable emollients. This put people at risk in case of a fire as these emollients are highly flammable. All staff were able to correctly describe their training and competency assessment process. Staff all identified they would read the PRN (when needed) protocol if someone needed PRN medicines. The manager confidently described how people were supported with their medicines in line with the medicines policy. The manager talked about having risk assessments and PRN protocols in place to guide staff how to administer medicines.