Ornate Health Care Derby

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. This is the first assessment for this newly registered service. This key question has been rated good.This meant people were safe and protected from avoidable harm.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider promoted a culture of openness and transparency. However, opportunities to further strengthen arrangements for robust and effective safeguarding oversight were identified.

We found not all incidents were referred to the local authority safeguarding team, which did not ensure concerns were escalated to the relevant agencies in a timely manner.

Systems were in place to ensure learning took place when things went wrong and shared with the wider staff team. Leaders told us that the quality manager monitored trends and lessons learnt. For example, the quality manager had identified carers were not completing notes clearly and supported staff on how to write notes, sharing good practice and as a result notes were now more detailed.

People told us they felt able to raise concerns. Staff described a supportive working environment and told us they felt able to raise concerns. A whistle-blowing policy was in place, which promoted openness and transparency and encouraged staff to speak up about any issues

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People’s needs were assessed before they started using the service, ensuring staff had the information required to provide safe and appropriate care. We reviewed 2 people’s care plans and risk assessments which had been reviewed and updated as needed. Comments from people included, “Yes, I get regular reviews about 6 months, as my needs are changing” and “Yes, the manager comes out quite regularly to review the care plan.” However, 2 people told us that their care plan had not been reviewed recently. We discussed this with leaders who confirmed they would address this as care plans were reviewed every 6 months, or earlier should there be a change in the person’s circumstances.

The provider worked with people and healthcare partners to understand what being safe meant to them. However, the provider did not always report safeguarding concerns appropriately.

Leaders had not always taken appropriate action when safeguarding incidents had occurred. This included not always reporting safeguarding concerns to external agencies such as the local safeguarding team and CQC. We discussed this with leaders, who confirmed that the 2 incidents we identified would be referred retrospectively to the local authority safeguarding team.

People told us they felt safe with the care they received. Comments included “Yes in the main I do feel safe, but it’s very varied care” and “I feel completely safe.” Staff understood their responsibilities in keeping people safe. They were confident in recognizing signs of abuse or suspected abuse. This helped ensure people were protected from the risk of harm. A staff member said, “We have been trained on how to spot the signs of abuse and discussed in staff meetings.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Peoples care plans included information about their individual care needs. Staff told us leaders kept them up to date when people’s needs changed and felt that care plans and risk assessments gave them enough guidance to support people safely. One staff member said, “A person required a modified diet and thickened fluids to reduce the risk of choking. I checked that the correct food texture and fluid consistency were provided according to the prescribed level. During mealtimes, I monitored the person encouraging them to take small bites and allowing enough time for them to swallow safely without feeling rushed.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Care plans included information to ensure a safe environment, which included identifying and managing potential hazards. Staff commented that if they had concerns about the safety of the premises or equipment, they would escalate this to management. They also stated they carried out visual checks of equipment to ensure there were no concerns.

The provider did not always make sure there were enough qualified, skilled and trained staff and recruitment procedures were not always robust.

We reviewed the training matrix and found that a couple of staff members were not up to date with some training. We discussed this was leaders who confirmed that the staff members had completed the training, but this had not been populated by the system. The training matrix showed that the registered manager was not up to date with their training as they had been off from work. We received confirmation of timescales for the completion of training by the registered manager, ensuring they would be up to date with the required training.

People told us that they had no problems with staff not turning up to calls. However, one person said, “There are no set call times” and another person told us they required 2 carers, but often they arrived separately and normally late, therefore wanting to leave quickly. We discussed this with leaders who explained that people had scheduled call windows and recognised that occasional delays may occur due to traffic challenges and informed people of any delay.

Leaders confirmed that as part of their service improvements, they were enhancing staff mobility arrangements to support more timely visit delivery.

We found most checks had been completed when staff were recruited. However, we found that one staff member commenced employment before the provider had completed the Disclosure and Barring Service (DBS) checks. This did not ensure the providers recruitment processes were always robust to support them to make sure staff employed were suitable to work at the service. We discussed this with leaders, and they confirmed that the staff member now had a current DBS check in place which we saw.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected from the risk of infection and told us that staff wore personal protective equipment (PPE) when supporting them. The provider had systems and processes to assess and manage the risk of infection. Staff confirmed that they had access to PPE. Staff training records confirmed majority of staff had completed infection prevention and control training and a couple of staff were booked to complete the training.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines processes did not always provide assurance of safe administration.Two care plans we reviewed did not contain clear guidance for staff on how these people’s medicines should be administered, including the level of support they required to take their medicines, the time of administration or the route. For example, one person’s care records stated, “[Name] requires a structured and consistent daily routine to complete essential tasks such as medication.” There was limited information on how this should be done. This increased the risk of people not being supported consistently or receiving their medicines safely. We discussed this with leaders who agreed to take immediate action to address this, explaining that they will ensure where medication support is provided this will consistently be reflected within all care plans. A copy of another person’s care plan was submitted which contained medication administration details and the support the person required.

Medicines audits were carried out to ensure any discrepancies were identified and followed up. However, these had not identified the shortfalls picked up at this inspection.

People told us when staff supported them with their medicines they were satisfied with the support provided.