Gloucestershire Community Support Services

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 Good. At this assessment the rating has changed to 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service was working towards promoting a culture of openness, learning, and improvement. Incident investigations were completed and clear outcomes were communicated to staff to ensure lessons learned in staff team meetings. Duty of candour was considered and followed as appropriate. Risks associated with closed cultures were mitigated by observations by the internal Positive Behaviour Support (PBS) team and spot checks daily by the manager. The manager told us, “When I observe practice which is not in keeping with the care plan, I meet with staff to reflect and identify where practices can be improved.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People and their families were involved in pre-assessments where appropriate. Staff told us handover information for newly admitted people or re-admitted people was clear. Referrals to external health professionals were made in a timely way. However, we found limited evidence which showed people were involved in the process of planning to move between different services. We found referrals recorded on the electronic recording system often lacked specific details, such as who the referral was made to and if changes made to medical needs were effective or not.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The provider did not always adhere to the principles of the Mental Capacity Act 2005 or ensure people’s rights were safeguarded. For example, people had not been given information in a way which they could understand for CCTV being used in communal areas and decision specific mental capacity assessments completed were not detailed or person-centred. The provider had been receptive to feedback around this and immediately actioned turning off the CCTV for one of the communal lounges which was only being used by 1 person. However, a decision had been made which could not be shown to be in people’s best interest. This meant people were at risk of discrimination and their rights not being upheld. We were not assured restrictive practices were being used in a way which was legally justified, proportionate, necessary and as a last resort. The provider had authorisation records related to people’s deprivation of liberties. Staff had received training and were able to explain how they would safeguard people. People told us they felt safe and liked living in their home.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found people were experiencing restrictions without sufficient evidence to show other options had been considered, discounted, and why the restrictions in place were the least restrictive option. For example, we found one person had locks on their fridge and food cupboards, but the risk assessment for this was not clear on how this decision was made and how it supported the person to take positive risks. There was no mention of these restrictions in the person’s care records. Staff we spoke to were unsure about why the locks were in place. The provider was very receptive with our feedback and on the second day of the inspection the locks had been removed except for where cleaning chemicals and medicines were stored. The provider was also working on completing a new decision risk assessment and updating the care plan. However, we were concerned this had not been picked up by the staff or managers prior to our inspection.

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

The provider had risk assessments related to the environment and completed regular fire evacuation drills and safety audits. We saw evidence people had been consulted about the environment to ensure adaptations and reasonable adjustments were made to meet their individual needs. However, there was evidence of a leak in the ceiling of the apartment block which had not been fixed, and the ceiling had not been repaired. We saw evidence this had been reported to the landlord. We also saw some uneven flooring in people’s flats and bungalows, which again, although not the responsibility of the provider, could be a risk to people. However, we were not assured appropriate risk assessments had been put in place to mitigate the risks posed by the water leak and the uneven flooring while the service awaited the landlord's repairs.

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.

Staff had completed training relevant to their role, to enable them to support people safely. The provider supported staff with regular supervision. Staff were deployed in line with the services dependency tool. People told us they liked staff. Staff skills and competency had been assessed to ensure they could meet individual people’s needs. When people received one to one support the staff’s skills and experience had been matched to the needs of the person which enabled people to work towards and achieve their aspirations and potential. For example, the provider had received feedback from staff and relatives about a decrease in outings over the last few months. It was found the cause was a lack of staff who were drivers. The provider supported staff with obtaining the relevant licenses and increased the number of drivers. We found staff were recruited safely.

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 and relatives said the service was clean, feedback included, “Their apartment is always nice and clean.” People were supported to understand and follow safer infection prevention and control because the provider had given people easy read documents which helped them understand safe hygiene practices, such why handwashing was important when cooking. We saw people’s home environments were clean and hygienic and staff were seen cleaning across the site visits. The provider’s cleaning schedules evidenced the cleaning completed. Staff regularly audited the effectiveness of the infection control processes. The manager was working with staff to improve cleanliness standards by discussing with the night staff how they can ensure the communal areas are cleaned during the night. Staff had completed training in infection control and hand hygiene and had access to relevant guidance. Staff were observed to wear the personal protective equipment (PPE) provided appropriately. There was guidance displayed to prompt people for example, about the importance of hand washing. We observed there were enough stocks of PPE but fed back they only had gloves in one size, and the PPE room was being used to store other items. The manager took immediate action and removed the other items and ordered new gloves in a variety of sizes.

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

Information on people’s medicines was accessible, and information was provided to people with a learning disability and autistic people in a way they could understand. For example, while we could not find information supplied to people showing pictures of the tablets they were taking and what they were for, we did find people were given information about the importance of taking medicines in individualised ways. One person had information given to them on an electronic device and care records clearly documented how people would show signs of being in pain and how they wanted to take their medicines. For medicines administered when required, there was not always a protocol in place to assist staff, some lacked detail, and others had the wrong person’s name on them. Staff told us missing protocols were because the person did not normally ask for or need those medicines, but they had not been removed from the charts. The provider acted on our findings the same day and updated all protocols and care plans.