Archived: Sovereign 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 Good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment the ways people’s medicines were managed, infection control, fire safety and the deployment and training of staff.They had also failed to learn lessons when things went wrong.

This service scored 31 (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 have a proactive and positive culture of safety, based on openness and honesty. They did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider and registered manager did not have a process in operation to review accidents and incidents to look for patterns and trends. We expect providers to have a system in place to identify any patterns and trends, such as the type of accident, or the times or place they were occurring and act to keep people safe.

Accidents had been recorded but not effectively reviewed to identify if any actions were required to mitigate the risk of them occurring again. For example, a person had fallen shortly before our inspection. Their falls risk assessment and care plan had not been reviewed to ensure all actions had been taken to mitigate the risk of the person falling again. This placed the person at continued risk of harm.

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

The registered manager did not have systems in operation to ensure staff had all the information they needed to provide people’s care and support when they moved into the service. Staff did not have care plans and risk assessments providing basic guidance before people moved in, to keep them safe. For example, there had been a gap of over a week between 1 person moving in and their care plan being agreed with them. There was a risk people would not receive safe, consistent care and treatment in the way they preferred when they began using the service.

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.

Strategies had been put into place by the Police and local authority safeguarding team to protect people from the risk of abuse by people outside of the service. However, detailed guidance about how to protect people had not been provided to staff. There was a risk the strategies would not be followed and people would be put at risk of further harm.

Staff described how they recognised and reported abuse including to external agencies if required. They were confident the management team would take the appropriate action when they raised concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. A person had a DoLS in place and an application to renew it had been submitted before the DoLS ended.

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

Risks to people had not been robustly assessed and action had not been planned to mitigate risks. For example, care had not been planned to mitigate the risk of people developing pressure damage. One person used a special mattress to reduce the risk, this was set to 90kg. Staff were unable to weigh the person and we could not be assured the mattress was set correctly. Care had not been planned to support the person to change their position regularly. Not repositioning the person regularly increased the risk of them developing skin damage.

Another person had fallen several times, the risk of them falling had been assessed but again action had not been taken to mitigate the risk. Staff were unaware when the person was moving around without support and the person had fallen and sustained an injury.

Some people used equipment to assist them to stand or transfer from bed to chair. Detailed guidance had not been provided to staff about how to move people safely, including the equipment and techniques to use. This left people and staff at risk of injury.

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

Effective action had not been taken to keep people safe in the event of an emergency, such as a fire. The provider’s fire risk assessment had identified actions needed to be taken to keep people safe, however, the provider was unable to tell us what actions had been completed and if any were outstanding. Fire evacuation equipment was not in place to support staff to evacuate people safely. The provider told us they would move 1 person using a bed sheet. Other people’s Personal Emergency Evacuation Plans (PEEPS) instructed staff to ‘wheelie’ them down the stairs in a wheelchair. This was not safe practice and increased the risk of injury to people and staff. We shared our concerns about fire safety with Kent Fire and Rescue Service following our site visit.

There was no comprehensive call bell system in operation at the service for people to alert staff when they needed assistance. People relied on ringing a bell or using the phone in their room. The bell only alerted 1 staff member that people needed assistance and there was the risk people would have to wait for the support they needed. Systems to alert staff that people were at risk of falling, such as alert mats, were not in operation and staff did not know when people at risk of falling were moving without support. One person at risk had fallen without staff’s knowledge and sustained an injury.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff had not always been recruited safely. Robust checks on candidates conduct in previous social care roles had not been consistently completed. This included checking with some previous employers and following up on negative references. There was a risk staff did not have the experience needed to fulfil their roles.

Staff had not completed a robust induction before they began working with people. The induction did not cover the practical skills staff needed and their competence to provide care safely had not been assessed. There was a risk staff did not have the skills they needed to provide safe care.

Leaders and staff did not have the skills they needed to provide safe and effective care. The provider and registered manager both provided care to people. Neither had completed basic training to undertake these tasks. Staff had not taken part in practical training provided by suitably skilled trainers. For example, the registered manager had trained staff in moving and handling people. They told us they had completed their ‘train the trainer’ training in 1997 but had not undertaken refresher training to make sure their skills remained current. Staff had not completed practical fire safety training and had not had the opportunity to practice evacuating people. This left people at risk of injury.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The provider was not following national guidance and their own policies to protect people from infections risks. For example, staff did not have access to liquid soap and paper towels at all handwashing sinks and people shared toiletries, including bars of soap and fabric towels in communal bathrooms. The provider removed these at our request.

The provider did not have a cleaning schedule in operation to ensure all areas of the service and equipment were cleaned regularly. Staff emptied commodes down the toilet and rinsed them out in handwash sinks and no systems were in operation to decontaminate commodes between each use. This placed people at increased risk of infection. Staff’s competence to wash their hands and clean effectively had not been checked to make sure all staff were following best practice guidance and the risk of the spread of infections was managed.

Checks on infection control practices had not been completed in line with the provider’s policies. The provider was unaware of the shortfalls we found and they had continued unaddressed, leaving people at risk of becoming unwell.

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

People’s medicines were not stored safely. The temperature that some medicines were stored at had not been checked to make sure they were stored in line with the manufacture’s guidance. Storing medicines at too high or low a temperature can reduce their effectiveness. Medicines which required refrigeration were stored in a fridge with food, and were accessible to staff, people and visitors. There was a risk the medicines would not be stored at a safe temperature. They were also at risk of misappropriation and medicines would not be available to people when they needed them.

Systems and processes were not in operation to ensure ‘when required’ (PRN) medicines, including pain relief and laxatives, were administered safely and in line with guidance from the prescribing healthcare professional. No guidance had been provided to staff about when medicines should be administered, the maximum dose to administer in a 24-hour period and the action to take if they were not effective. This left people at risk of pain and discomfort and becoming unwell because too little or too much medicine had been administered.

Some people were prescribed medicine to treat or prevent blood clots. Risks that people may bleed or bruise more than normal because their blood would not clot as easily had not been assessed. This left people at risk of not receiving the treatment they needed to keep them safe and well.

Effective processes were in operation to order, record and dispose of medicines safely.