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. At our last assessment we rated this key question require improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The provider had a system in place to learn when things went wrong. All incidents were logged by staff on a relevant incident form. Each month these were reviewed by the registered manager to consider any learning. There were no incidents recorded at the time of the inspection. However, the review process included a review by the registered manager and consideration of whether other agencies needed to be notified about the incident. Staff were aware of the need to document and report any incidents. A staff member told us, “There is a procedure to follow for incidents or accidents, you have to report it, we have to complete the form and notify the registered manager.” The registered manager told us they reviewed all incidents using a lessons learned approach and shared the outcomes of this with staff in regular meetings and supervision sessions

The provider had systems in place to maintain and monitor safe care delivery; however, these were not consistently used. The provider had systems in place to support people with transitions into the home. Relatives told us they were involved in the initial assessments and care planning for people when they first came to the service. However, we had mixed views about how they remained involved in people’s care. A relative told us they had not had a meaningful review to understand their relative’s progress and the outcomes they had achieved for some time. We saw reviews of risk assessments and care plans had taken place internally, however relatives had not been asked to be involved for some time. We spoke to the registered manager about this and they told us, they would address this with relatives. Care plans lacked details about the short-term goals for people and what they had achieved. For example, 1 person had been working with staff to access community resources and there was limited information in the care plan about how the person had been supported and their achievements. We spoke to the registered manager about this, and they confirmed they would contact relatives to hold reviews and share information about people’s achievements.

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 told us they liked living at the home and relatives told us they felt people were safe. A relative said, “[Person’s name] is safe and they are happy.” Staff could describe the different types of abuse and what they would look for. Staff understood how to raise concerns and seek appropriate action. A staff member said, “If I had concerns, I would inform the registered manager and escalate it. If the registered manager didn’t act, I would inform the Local Authority or CQC.” The registered manager told us, they had not had any safeguarding incidents since the last inspection and records we saw supported this. There was a safeguarding policy in place, and all staff had received training in safeguarding procedures, and the registered manager had a system in place to monitor incidents when they occurred.

The provider’s systems to manage risk did not consistently ensure detail was captured in risk assessments and changes were made when risks changed. However, staff understood how to manage risks to people’s safety and improvements were needed to ensure documentation matched staff practice. The registered manager undertook monthly reviews of all risk assessments and care plans, however this had not identified where plans needed a change or more detail. Where people were at risk from distressed behaviours, risks were assessed and plans were in place to minimise distress and help people feel regulated. However, some of these plans required updating to ensure they reflected improvements in this area. Some plans lacked detail on specific conditions or needs. We spoke to the registered manager about this, and they said they would review peoples risk assessments and plans. People were observed being supported to manage risks to their safety. For example, people were able to access the kitchen and take part in preparing their meals and drinks with staff supporting them to ensure their safety. Relatives told us staff understood how to keep people safe. Risks to people’s safety had been assessed and plans had been put in place to minimise them. For example, risks relating to health conditions, nutrition, hydration and medicines.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Relatives had mixed views about the home environment. Some felt this was a nice, homely place and others felt whilst some areas had improved, more could be done. We spoke to the registered manager about this and they told us, they would speak with relatives to understand any concerns they may have around the environment and address these. Systems were in place to ensure the environment was safe. Risks relating to people’s environments were assessed and steps taken to reduce them. Safety checks were completed regularly and there were systems in place to address fire safety.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We saw staff had received training in supporting people including specific training around learning disabilities and autism. People were observed to always have access to staff. Relatives did not express any concerns about the number of staff available to support people and confirmed staff had the skills to keep people safe. Staff told us there were enough staff to support people and records confirmed staff were available. Staff were recruited safely. The registered manager had a recruitment policy, and checks were carried out to ensure staff were suitable to work with people. Staff had in induction into their role and received regular updates to their training. A staff member told us, “The induction was good and the staff and registered manager support you with anything you are not sure about, initially we have to work with a more senior member of staff.”

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 observed using protective aprons and washing their hands before assisting with meal preparation. Relatives told us they had seen staff use protective equipment when supporting people. Staff told us they had received training in infection prevention control, and they had access to Personal Protective Equipment (PPE). The provider had a policy in place to guide staff practice and there were cleaning schedules in place and audits to monitor the process. The registered manager told us, there were regular checks in place, and they understood how to raise any concerns about reportable infections.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People were supported to take their medicines as prescribed. Relatives had mixed views about medicines management. A relative told us they did not feel medicines reviews were undertaken at the right frequency and they had not been involved in discussions about their relatives’ medicines. We spoke to the registered manager about this and they told us, people did have regular reviews of medicines with relevant professionals. Records we saw supported this. They shared examples of where people had previously been prescribed behaviour management medicines and how these had now been reduced. Staff had received training in how to administer medicines safely. Staff could describe how they supported individuals to take their prescribed medicines in line with their risk assessment and care plan. Medicines were stored safely and checks were in place to ensure medicines were stored at the right temperature. Medicines administration records were accurately completed and there were checks in place to ensure there were sufficient medicines available.