Jaden 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 inadequate. At this assessment the rating 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 provider was previously in breach of the legal regulation in relation to safeguarding and peoples safe care and treatment. Sufficient improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The providers procedures had ensured that incidents had been recorded. One incident report did not contain sufficient information to identify the events that occurred. This was highlighted to the manager who was responsive to the feedback.

There had been few accidents, action had been taken where these had occurred. Families said they could raise concerns, and that they will be listened to. People could raise concerns including externally. Staff felt they could raise concerns, and they would be listened to.

We found no concerns in relation to Safe Systems, pathways and transitions at this inspection. The service worked with people and family members to establish and maintain safe systems of care.

Although the provider worked well with people to understand what being safe meant to them and how to achieve that, they did not always share concerns quickly and appropriately with partner organisations The registered manager was able to explain safeguarding reporting procedures, however they had not followed this on all occasions. This meant vulnerable people may have continued to be at risk of harm.

Staff understood the signs of abuse and who to report their concerns to and had completed safeguarding training. There were appropriate policies and procedures in place however, the management team had limited understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). The need for DoLS applications had not been identified for a person who was being supported 24 hours a day and was not free to leave without staff support. There were restrictions on people and the registered manager could not fully explain why these were in place.

The service did not always work well with people to understand and manage risks. Risks to people were not always balanced with their freedoms, privacy and rights. Restrictions to people, such as not allowing alcohol on site or restricting visitors, were not risk assessed and evidenced to be necessary to reduce risks to people.

Risk information about people was not always consistent. For example, one person was at risk of choking. Their care plan included some, but not all of the information on foods to avoid due to their risk of choking, as advised by speech and language therapists. The care plan did not state what action staff should take should the person choke. This meant staff were not informed of all relevant information to manage the risk.

There was no documented evidence of the person or their family’s involvement in their care plans and risk assessments. Not all care staff had completed the provider’s training in relation to risk.

The service detected and controlled potential risks in the care environment. They made sure equipment, and facilities supported the delivery of safe care. The home was suitable for the people living there. People were happy with their private spaces (bedrooms), had access to a range of communal areas and were seen using these throughout the inspection. Systems and procedures were in place to ensure the safety of the environment.

There were not always enough suitably qualified, skilled and experienced staff. Staff had not always received effective support, supervision and development or completed all the provider’s required training. New staff had received a probationary meeting however, the probationary policy stated that, “Their performance will be formally assessed at least twice during the probationary period”. Records showed this was not always the case.

Staff told us they found their probationary meetings and supervisions useful however, there were gaps in the frequency of these. Most training was up to date for staff as required for their role and related to people’s needs, there were some inconsistencies in what was identified as required training for staff.

Suitable processes were in place and had been followed to ensure the safe effective recruitment of staff including ensuring all pre-employment checks had been completed. There were enough staff on-site when we visited.

The service assessed and managed the risk of infection. The home was visibly clean, and staff had access to personal protective equipment such as gloves and aprons for when they required this. Staff had completed relevant food hygiene and infection control training.

The service did not always make sure that medicines were safely managed. Some medicines were prescribed to be administered when people required these. Care plans and medicines administration records lacked details as to how or when staff should administer these. Medication was stored securely. However, there was a risk that these may be damaged and therefore less effective due to excessive temperatures as maximum and minimum temperature checks of storage areas were not in place. The registered manager agreed to take the necessary action to ensure the safe management of medicines.