The Spinal Unit Action Group

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.

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

People were very positive about their experiences of the care they received at the home. People told us they felt safe and were treated well, they also told us they were confident about raising any concerns about their safety. Their comments included, “Couldn’t ask for a better place and better staff, they look after me so well, not a bit worried about my safety if I was, I’d tell one of the staff” and “Very safe indeed, being unsafe has never crossed my mind. I’d certainly tell someone if I had any worries at all.” People told us staff supported them safely with the right equipment to enable them to move around the environment independently. One person told us, “I feel safe when they [staff] help me into my wheelchair, they take their time and make sure I’m ok,” People told us their bedrooms and other communal areas were kept clean and hygienic. One person said, “My room is cleaned every day” and another person said, “Everywhere here is kept nice and clean.” People told us they knew what medicines they were prescribed, and staff provided them with the right support to make sure they received them on time. One person said, “I always get my tablets bang on time” and another person said, “They [staff] prepare my medication and hand them to me as I can take them myself, they sign the record after I’ve taken them.” People were complimentary about the registered manager, their comments included, “[Managers name] is great, cares a lot,” “Think [managers name] does a great job, can talk to them about anything” and “[Managers name] always takes time to speak with me.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. For example, staff worked well and shared relevant information with other professionals such as specialist nurses, physiotherapists and occupational therapists.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately. The provider had not established a formal system or process for recording safeguarding concerns. For example, there had been 1 safeguarding concern raised in the last year and whilst we were assured this was acted upon appropriately there were no records kept detailing the concern, immediate action taken to safeguard people and the investigation and outcome. However, staff had completed safeguarding training and were confident about recognising and reporting safeguarding concerns. People told us they felt safe and would tell someone if they had any concerns about their safety.

The provider did not always work well with people to understand and manage risks. Risk assessments had not always been completed to identify potential hazards and risks associated with certain health conditions some people had such as diabetes and epilepsy. There was no information in place to guide staff on or how to recognise and respond to any complications associated with the conditions. A member of staff was unsure of the signs and symptoms which may indicate complications associated with diabetes such as increased blood sugar levels. However, people felt staff understood the risks they faced and managed them well.

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 required safety checks had not been carried out on the environment and equipment to ensure people’s safety. For example, the last safety check on portable appliances (PAT) expired in October 2024 and fire alarm tests and drills had not been consistently carried out. However, regular safety checks were carried out on equipment people used to help with their independence such as hoists and wheelchairs. Following our site visit the registered manager assured us the required safety checks were completed on portable appliances and fire equipment.

The provider did not always make sure staff received effective support, supervision and development. Whilst staff told us they felt well supported they had not received formal supervision and appraisal in line with the providers staff supervision policy. The policy stated each member of staff will receive 6 (bimonthly) supervision and a formal job performance appraisal and training review every 12 months. However, the provider made sure there were enough qualified, skilled and experienced staff. The staffing rotas showed the right amount of suitably skilled and experience staff were on duty each day and night. Following our site visit the registered manager assured us they had commenced staff supervisions in line with the providers policy.

The provider did not always assess or manage the risk of infection. For example, there no audit system in place in line with current relevant guidance to assess or manage the risk of infection. Some face masks held at the home were past their expiry date by several months increasing the risk of them being ineffective. However, the environment and equipment were kept clean and hygienic, and staff were observed following safe infection prevention and control practices. Following our site visit the registered manager assured us the face masks were disposed of.

The provider did not always make sure medicines and treatments were safe. The process in place for ensuring safe management of medicines was not robust. For example, whilst weekly stock checks of people’s medicines were completed, there was no audit system in place for reviewing other medication practices such as administration, documentation, disposal and staff competencies.However, staff involved people in planning, including when changes happened. We observed people’s medicines were safely stored and recorded and people told us they knew about their medicines including any changes and that they were administered to them in the right way and at the right times.