Jaytee Care Demi House

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 service. This key question has been rated Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of 2 legal regulations in relation to safeguarding and fit and proper persons employed.

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness. Lessons were not always learnt to continually identify and embed good practice.

Records showed staff had received induction and training to report and manage safety events. However, we could not be assured that safety events were being fully documented, reported, reviewed and used for learning. For example, the level of detail used to document accidents and incidents was mixed, with some containing very limited information and not being reviewed by the provider for understanding and learning. Despite the occurrence of documented accidents and incidents, relatives told us they were not aware of their relations having been involved in such events. When we spoke with the provider about this, they told us what the process was for reviewing accidents and incidents, and acknowledged the process could be better. This meant people were at risk of safety events not being appropriately managed.

The provider did not always ensure safe systems of care. They did not always manage or monitor people’s safety.

Effective systems were not in place to ensure safety was consistently monitored and managed at the service. For example, as reported on under our safe environments, some environmental risks had not been identified or acted upon to ensure people were consistently safe.

However, effective systems were in place to ensure people’s needs were appropriately assessed before being admitted to the service. The provider told us the transition process for people before they are placed at the service was a comprehensive one, which included observing people in their previous environments so they were able to observe their needs.

The provider said that assessment plans were then developed from this process, which were used to create people’s care plans and risk assessments. This was supported by relatives, who said the process was good and that it involved themselves.

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, abuse, discrimination, avoidable harm and neglect.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. However, despite people being in receipt of 1 to 1 staff supervision at all times and not being free to leave the premises without staff supervision, we found people did not have up- to-date DoLS authorisations in place. This meant that people were being deprived of their liberty without the necessary legal authorisation.

There was a safeguarding policy in place, records showed that staff had completed safeguarding training and staff were able to tell us the action they would take if they had concerns, with 1 staff member saying: “Staff would report concerns straightaway.” The provider also told us how safeguarding concerns would be reported to the local authority so they could be investigated and when we spoke with the local authority, they informed us they did not have any safeguarding concerns about the service. Furthermore, relatives told us they felt their relations were safe at the home.

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

We observed that people’s care plans and risk assessments provided clear, detailed and robust information about people’s assessed needs and risks, which guided staff in providing safe, consistent and proportionate support. For example, we observed that behaviour care plans and risk assessments contained person-centred behavioural strategies which guided staff in how to recognise and minimise incidents of people experiencing emotionally-heightened behaviour in a clear and proportionate way.

The information staff told us about people’s needs demonstrated good awareness of the risks associated with people and how these could be supported. For example, 1 staff member told us how staff had supported a person to improve their road safety awareness and how this had improved their awareness of road hazards. Relatives also told us that staff supported people to reduce risks to their safety.

The provider did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

We were not assured that all environmental risks had been identified and acted upon. We observed that radiators and associated pipework did not have covers to protect people from the potential risk of burns. Furthermore, the radiator risk assessment we viewed did not show how radiator temperatures were being managed to ensure temperatures did not reach high levels. We also observed a toilet seat in 1 of the bathrooms which was very loose and unsafe. This placed people at risk of harm.

We viewed health and safety checks, environmental audits and service certificates. However, these checks and audits had failed to identify the environmental concerns listed above; therefore, we could not be assured there was effective oversight of environmental safety.

However, staff feedback demonstrated their awareness of some elements of environment safety processes. Staff training records also showed staff had completed training in health and safetyand fire safety.

The provider did not make sure there were robust and effective recruitment processes in place to ensure the suitability of new staff.

The recruitment records we viewed did not demonstrate that safe and robust recruitment practices were always carried out. For example, some of the recruitment records were missing a full employment history, explanations for employment gaps and appropriate references. This placed people at risk of receiving care from unsuitable staff.

However, people were supported by appropriate levels of staffing. We observed that staffing levels reflected the service rota and people’s care plans, which meant additional staff were available at certain times of the day to ensure people could access the wider community safely. Relatives also told us staffing levels did not fall below agreed levels.

Staff were appropriately trained. The service’s training matrix showed staff had received a range of training which included training specific to people’s needs, such as learning disability and autism awareness training. We observed staff supported people in way that demonstrated they were appropriately trained, this included the ways in which they communicated with people and understood their needs.

Staff told us the provider and team leader provided support to them when required and records confirmed staff received supervisions and attended team meetings.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Infection prevention and control (IPC) training for staff had expired which meant we could not be assured staff had access to the most up to date and safe practices within IPC. Provider audits of the service had not identified that some bathroom seals were in poor condition or that a toilet seat was loose. These issues posed a potential IPC risk to the people who used the service. However, we saw the home was clean. This was supported by relatives, who told us the home was clean and that staff wore PPE when required, with 1 relative telling us: “It’s very clean and homely. They wear gloves and everything.”

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

’As required’ medicines failed to have corresponding protocols to provide staff with direction regarding their use. Furthermore, when these medicines were documented on people’s Medicines Administration Records (MAR) as having been administered, the reason for this being the case was not always documented. This meant we could not be assured that people were being provided their ‘as required’ medicines safely and in accordance with best practice and guidance.

However, the service’s training matrix showed that staff had received adequate medicines training and the staff we spoke with demonstrated good awareness of people’s needs and preferences regarding their medicines. Relatives also told us they felt staff supported people well in this area. We observed medicines were stored appropriately and there was a clear process for ordering and receiving medicines.