Jubilee Mews

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 the last inspection we rated this key question good. At this inspection 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.

Staff had a proactive and positive culture of safety, based on openness and complete honesty. However, the provider did not always address concerns about safety in a timely manner. Lessons were not always learnt to continually identify and embed good practice. We found despite staff repeatedly warning about safety risks since the service started accepting people with self injurious behaviours including significant, potentially life-threatening actions and people who assaulted staff. The provider had taken no action to review or strengthen the staff deployment. Also for 4 years the provider had been aware the soundproofing in the office was insufficient to ensure confidentiality. Although this had been raised with NHS property team who owned the building no action had been taken. A staff member said, “I have raised the issue of confidentiality multiple times over the past 4 years because of the location of the office. When sitting in the house lounge by the office you can hear what is being said in the office even if people are talking in a normal tone and volume. People have reported they heard staff talking about other service users. Sound proofing or converting one of the garages has been proposed but neither have been actioned yet.”

Systems were in place to ensure safe care pathways and transitions. However, the provider had not always established and maintained safe systems of care. When accepting people into this rehabilitation service the assessing team had not wholly considered if the person’s needs could be met and the impact their behaviour might have on others. This had led to several people being admitted who had great difficulty regulating their emotions and often a domino effect was seen whereby one person self-injured and then another person did so. Although risk assessments were comprehensive and regularly reviewed, which enabled staff to manage presenting risks effectively, the impact of these impulsive behaviours and current staffing levels meant they could not always be mitigated. When staffing levels were at the minimum number of 2, they could not support multiple people injuring themselves or take people to hospital if this was needed. The provider has undertaken to immediately address and resolve this issue.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately. When incidents occurred, staff completed a full investigation and took a proportionate, balanced approach when dealing with them. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. Records showed safeguarding incidents were investigated and lessons learned were shared with the team. Staff understood when Deprivation of Liberty Safeguards (DoLS) authorisations would need to be sought and what to do if there were conditions imposed. Some people were subject to the powers of Mental Health Act 1983 (amended 2007) and staff had a good understanding of how to ensure these requirements were met.

Staff worked with people to understand and manage risks by thinking holistically about them. However, they could not always manage to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place and assisted staff to identify how to mitigate risks. A staff member said, “Risks and risk management, residents have detailed nurse support and safety plans. Despite this I feel we need more staff particularly on a late shift or night shift when the majority of incidents take place with our more complex residents. Especially if two incidents are happening at once and we only have two members of staff on this can be a challenge to keep residents safe.” The provider took action immediately to address and resolve this issue.

The provider detected and controlled potential risks in the care environment. People were supported to be as independent as possible within the environment. Environmental risks were assessed and addressed. The staff team knew who to contact when people might benefit from additional aids or equipment. The provider had installed CCTV cameras in communal areas and intended to activate them. We discussed the measures that needed to be in place prior to doing so. People, however, believed these were operational. Some people believed staff watched them at night because the cameras lit up. The registered manager stated although they had discussed the current position with people they would make it clearer to people they are not in use and if they are activated exactly when and what footage would be looked at.

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, but people frequently highlighted staffing did not always meet the needs of the service. The service was meant to support people to recover and progress, but it instead was supporting people with very complex emotional needs who required more long-term intensive, crisis‑level care. Some people regularly self-harmed and could physically assault staff. During the cross-over period staff levels met people’s needs but people frequently highlighted the lack of staff during the morning and evening. Having 2 staff covering mornings and evening/night-time was not effective and had the potential to be unsafe. The provider was in the process of reviewing staff deployment. A staff member said, “Spending qualitive therapeutic time with all residents can be difficult as staff find their time can be take up with the 2 of the more complex residents and this impacts on other service users.”

Recruitment practices were meeting requirements. The people’s team had developed robust training programme, which was effectively delivered, and they consistently evaluated its effectiveness. The team considered the impact this training had on how staff delivered the service and whether it was embedded into their practices. They consistently looked to see it assisted staff to effectively support people to improve their mental health and supported the organisation to embed the overriding culture of ‘Here so no one struggles alone’. The provider offered access to additional training including access to nurse training, apprenticeships, preceptorship and mentoring programmes. A staff member said, “Training has got better over the past 5 years, we have a portal with mandatory training and also quite a large range of other training which staff can engage with at their leisure. Staff have asked for other training to help deal with current residents who have a diagnosis of Emotionally Unstable Personality Disorder and Autism which I believe is in the pipeline.” The provider ensured Oliver McGowan training was completed by all staff. The clinical leads also undertook an approved online practitioner certificate training in autism and mental health to further support. Their training hub provided personality disorder training. The provider was also sourcing specific Emotionally Unstable Personality Disorder training.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff adhered to infection control protocols, including appropriate use of personal protective equipment (PPE) and regular audits.

Staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff who administered medicines had the appropriate training and competency checks. Storage areas were secure, and temperature checks were recorded. Medicine administration records (MAR) charts were accurate, and controlled drugs were handled in line with regulations.