Keys Hill Park

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.

The service was in breach of legal regulations in regard to staffing, safe care and treatment and safeguarding.

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 provider did not always have a proactive and positive culture of safety based on openness and honesty. Whilst the provider had systems in place to review events that happened, they did not have full awareness of staff concerns regarding safety, and we could not be confident that lessons learned were consistently applied throughout the service.

Whilst there were clear reporting systems and training for staff to ensure incidents were reported; Staff told us identified risks had not always been properly assessed and this placed them and people using the service at risk of harm. For example, a staff injury occurred because specialised protective equipment was not easily accessible at the time of the incident, and it was not clear when staff should use this equipment particularly, when incidents escalated quickly. Whilst risks from stairs and the general environment had been assessed prior to admission and kept under review we were not clearly able too see what actions had been taken to mitigate actual or potential risk either as a direct response to an incident or as staff got to know people better.

The provider and leaders had not always fully recognised the impact ‘changes’ could have on people’s mental well-being and stress they could experience over time. This had placed people at risk of unmet needs and expressing their anxieties and frustrations, with an increased risk of harm. These factors had not been fully considered and appropriate action had not been taken to reduce known risks or help prevent recurrences.

Processes in place to monitor incidents and accidents and share learning with staff, were not robust. Incidents within the service were collated and reviewed. However, this did not assure us that themes and trends were clearly identified due to the quality of the recording and inconsistencies in ensuring information was always uploaded onto the electronic record system.

Staff teams relied on informal debriefings from leaders to discuss events and any actions needed. Whilst we saw examples of lessons learnt from the minutes of area manager and manager meetings, we were not assured these were consistently shared with staff or the required action was taken.

The service did work well with other health and social partners to ensure a robust and coordinated transition for people moving into the service. However staff told us whilst there were good connections with other health and social care providers, some people had been admitted to the service without sufficient guidance in place for staff to safely support them. Staff told us they had raised concerns about this and the impact it had on safety. Whilst staff did get to know people and their needs, we were concerned a lack of robust assessments of environmental risks to ensure safe care for people using the service, was a priority.

Staff were not all aware of how to access essential information, such as people’s hospital passports. In addition, senior staff were not aware they could liaise with a learning disability nurse in the hospital, which could make hospital transitions safer. Following this assessment, the provider advised us that out-of-date paper records had been archived and there had been an audit of electronic records, to help ensure effective and up to date information was shared between services.

The service worked with other healthcare partners to understand and promote people’s safety. However, 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.

Risk assessments and guidance for staff to keep people safe were in place and were developed over time. We found however not enough emphasis had been placed on how people might experience sudden change, loss and trauma and the impact this could potentially have on their behaviour resulting in some significant incidents which placed both people and staff at increased risk of avoidable harm.

Guidance was in place for staff as to the actions they should take if a person should go unintentionally missing and the provider told us they had a good working relationship with the local community policing team.

Staff had training and knowledge of when and how to report concerns. However, some staff said they were reluctant to escalate concerns to the manager and reported being fearful of speaking up because of perceived consequences.

We were told that people using the service sometimes raised concerns about the conduct of staff. Although staff said these issues were addressed, records of these concerns failed to demonstrate whether they had been logged and reviewed as complaints or if action had been taken to prevent recurrence. Therefore, we could not be assured that all concerns were being listened to, taken seriously and escalated appropriately.

Where incidents met the threshold for safeguarding, these were recognised, logged and reported to the appropriate agencies. Financial safeguards were in place and spending activities were kept under review.

Risks were not always effectively managed because we were not confident that all staff had the necessary knowledge of people’s needs.

For example, agency staff were not given access to people’s electronic care records. This meant they completed handwritten notes for the people they supported. We saw these notes were not in any systematic order and there were occasions when a single sheet of paper contained notes about several different people. We were subsequently concerned that this did not comply with information governance requirements.

Agency staff told us they referred to people’s paper care plan records and the information in these was up to date. However, when we checked, we found the paper records had not been reviewed regularly.

Agency staff and newer staff could not tell us where to find important information about people, such as individual fire evacuation plans and hospital passports. Most records had been scanned in, but this was not consistent and there was a lack of uniformity.

Team leaders and deputy managers told us they did not always have time to scan information into people’s electronic records in a timely way, due to their workloads. Therefore, we could not be assured that staff were accessing and referring to accurate and up to date information for the people they were supporting.

We had concerns about staff ability and competence in respect of safely managing a person’s epilepsy. We found that not all staff had completed epilepsy training, and we were not assured that staff who were supporting them could recognise and accurately record the person’s seizure activity. Records we looked at were incomplete or not adequately detailed, to ensure staff would know when to take action to keep the person safe. Following this assessment, the acting manager confirmed they had amended the seizure care plan and fire risk assessment and updated the staff induction records, which would help ensure all staff knew what actions to take.

We were concerned that people were put at risk due to the absence of essential information relating to new admissions, and the lack of robust risk assessments. A lack of guidance and poor staff training meant that individuals experiencing extreme emotional distress and those with profound communication needs, did not always receive the support necessary to ensure their safety and wellbeing.

We found although ligature risks were assessed and reviewed, we were unable to see robust recorded actions to reduce the actual risk for those affected.

During our assessment we discussed out concerns about the ongoing security arrangements with the provider as staff and visitors expressed concerns about the safety and security of the site which was highlighted by an incident when a person left site in a heightened state of anxiety putting them at increased risk of harm. The provider assured us that the rights and freedoms of individuals were carefully balanced with the associated risks and any necessary restrictions required to promote people’s safety.

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.

Risks from fire safety had not been robustly assessed and staff lacked knowledge about how to act in the event of a fire. Grab bags and PEEPs (Personal Emergency Evacuation Plans) had not been consistently completed for people across the service. This meant we were not assured staff would know how to assist each person safely in the event of an emergency.

People’s accommodation and environments were individual in line with their needs and properties were generally well maintained. We acknowledged that some refurbishment was required, and the area manager told us that works were scheduled for the following year. However, maintenance staff were consistently on site and were usually proactive in completing any repairs required. We raised concerns about uncovered pipework and uncovered radiators, which put people at risk of scalding if they fell against these. The provider assured us that an audit and risk assessments of all hot surfaces would be conducted following our assessment visit.

Whilst many areas of risk had been assessed, we found that some risk assessments had not been completed fully.We raised concerns with the provider about equipment being in place without consideration of the restrictions and risks it may pose to others. For example, a stair gate had been put in place for the safety of one person. However, this had impacted on the freedom of movement of others. This had not been considered or mitigated.

The service did not always make sure there were enough suitably skilled and experienced staff who were familiar with people’s needs and able to effectively support them.

All staff completed basic autism, learning disability and mental health awareness as part of their induction. Additional learning disability training was being rolled out starting with the executive team. However, we were not confident that all staff had received a suitable level of training or had a good understanding of people’s needs. Regular staff told us this was evident when agency staff used the on-call system to ask for basic information about people’s needs.

Agency staff did not have epilepsy training or, Non-Abusive Psychological and Physical Intervention (NAPPI) training. Although the provider had recently enhanced the skills of its own staff by increasing the number of who had completed NAPPI training, this training was not extended to agency staff. Agency staff were sometimes required to work alone, supporting people who could show distress through behaviour.

The providers ‘restraint reduction audit report’ showed a reduction in the use of agreed and non-prescribed physical interventions. However, whilst we acknowledged that fully trained staff may have contributed to this, the wider roll out of NAPPI training had only taken place recently and had not yet been completed by all staff.

People and relatives told us, the changes to staff and high use of agency staff had an impact on the care provided. A person’s relative said, “I think they need more core staff, and they run a lot on agency. It has a negative effect on my brother.” Another relative said, “It's changed and so many agency staff. Not many regular staff left.”

The provider had made robust efforts to recruit new staff. However, there was still a high reliance on agency staff. There were 27 people using the service, including 2 people who had recently moved in, who required a high level of staff support. This meant it was important for all staff to have sufficient training and support to be able to keep people safe. There was a high number of new staff and agency staff who both needed to develop skills and understanding of people's needs through induction. We were not assured all staff had sufficient training and support prior to working alone with people to be able to safely support them.

We found the number of staff trained in some areas was insufficient to meet the needs of people. For example, there were not enough staff trained to administer medicines to people so they could be deployed in each house. This meant staff who were trained in medicines administration needed to cover more than one house. Whilst we were assured this usually worked well, and there were contingency plans in place we were concerned that should emergency medication be required, such as for epilepsy, there could be a delay in people receiving it. This increased the risks to people’s health and well-being.

Team leaders and deputies were required to oversee several buildings and told us they found this challenging, particularly when they were required to be the medicines lead, as well as covering shifts and dealing with emergency situations. We were therefore concerned that there was a lack of robust oversight in emergencies, including the risk of fire or a person needing urgent intervention. We discussed this with the provider, who took some immediate action to address our concerns.

The provider assessed and managed the risk of infection but standardization of audits and lessons learnt across site would improve infection control practices.

Staff completed infection control audits on a regular basis whilst they were on duty. However, the quality and consistency of these varied from house to house, and it was not clear how themes and trends from individual audits were used to inform best practice across the whole site.

Whilst several staff were unwell during our visit the provider assured us their illnesses were not connected.

We observed staff encouraging people were encouraged to help keep the service clean and tidy, particularly their own bedrooms.

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

We identified there were insufficient numbers of staff trained to administer medicines. Due to the layout of the service, staff trained in medicines administration were not available in each building and were administering medicines to people across a number of different houses. This meant we were not assured people would always receive their medicines promptly and there was an increased risk of mistakes, as staff were meeting different priorities. There was a risk people needing urgent rescue medications could have delays in receiving this, which could result in avoidable harm.

In addition, we found a lack of consistency in the oversight and audits for medicines varied from house to house.The temperature of people’s medicines were checked daily to ensure they remained safe and effective to use. Some medicines had been removed from people’s rooms due to excess temperatures which could impact on people’s autonomy around medicines. We also found both electronic and paper recordings of medicines, the latter were incomplete and could lead to confusion. We recommend that paper records are removed, to avoid duplication and confusion.

Staff who had received training in medicines administration had competency assessments completed prior to them carrying out medicine administration. We noted that medicines were kept under review to ensure they were in stock and remained relevant to people’s needs. Whilst we did not identify significant concerns with medicine administration, we did not complete a full audit due to different arrangements for medicines in each house.

People were supported to take their medicines in a way which met their needs and there were clear records around what medicines people took, what they were for and any potential side effects. Whilst staff administered most medicines, they told us one person’s goal was to be more independent with their medicines. We saw the person had been supported to achieve this and now took their medicines by themselves.