Sandpiper

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff did not always fully investigate or record safety events. Lessons were not always learnt to continually identify and embed good practice. However, the provider had a positive culture of safety based on openness and honesty.

Staff completed accident and incident reports. Some incident reports we reviewed had not been fully completed. This meant it was possible learning from the incident to prevent further similar incidents could be missed. The manager told us they were working with staff to include the level of detail required. The manager told us some staff debriefs were completed after more serious incidents; however, they were not recorded. Staff told us they were able to discuss incidents which had occurred. One staff member said, “We can discuss it with the manager, so we know how to avoid it in the future, it is helpful.”

The manager investigated and analysed accidents, incidents and complaints. The manager completed lessons learnt analysis and shared this with staff in team meetings to help prevent recurrence of similar incidents. The provider had completed a yearly analysis of themes and trends of incidents which had been shared with the staff team.

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.

Staff supported people to attend hospital appointments and admissions. People had an emergency pack which shared important information with health professionals. Where people found health appointments and hospital admissions difficult, risk assessments informed staff of how to support people.

The service made referrals for people when they required additional support from external health professionals, such as physiotherapists or mental health teams.

The manager was in the process of supporting a person who had communicated a wish to move out of the home. They had explored potential options with the person and shared information with the local authority.

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 manager reported any safeguarding concerns appropriately and recorded and monitored any required actions. Staff were aware of how to report any concerns and were reminded of the ways in which this could be done in team meetings. A staff member told us, “If you see something that could cause harm or risk to the people we support, we should report it to management. It is our role to protect people from harm.” People and their relatives told us people were safe. A health and social care professional said, “I have had no cause to raise a safeguarding regarding my clients, nor have I witnessed anything that has given me cause for concern.”

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. We found DoLS authorisations had been applied for, and where authorisations had been granted any conditions of the authorisation had been met. Where there was a delay in DoLS assessments being completed for people, the manager periodically contacted the local authority to check on progress. They had completed mental capacity assessments for people to ensure any restrictions were recorded and had been agreed as the least restrictive option.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were clear care plans and risk assessments which recorded specific guidance on how people were supported to manage risks in their care. They were regularly reviewed.

People had detailed positive behaviour support plans which recorded any known triggers and individualised approaches to support the person.

Where people chose to make unwise decisions, they had been discussed with the person and there were individual approaches to managing these. People’s choices were respected.

Staff were trained to respond to risks associated with people’s care, such as risks of choking and behaviours of distress.

Where people were at risk of choking, staff followed guidance provided by speech and language therapists (SALT).

The manager had identified clearer guidance was needed to support people who may be at risk of constipation and planned to ensure this guidance was created.

A health and social care professional said of one person, “Risks in their care are well managed, they have good working relationships and know 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.
Although the premises was largely well maintained there were some areas of risk which needed to be addressed to ensure it was always a safe environment. For example, ensuring hazardous cleaning chemicals were always stored securely.

Some communal areas of the service and people’s bedrooms required redecoration or repair. Some people’s furniture also required repair or replacement to ensure they were safe and met people’s needs. For example, some people’s furniture was broken. A communal bathroom also required repair to ensure it was able to be cleaned effectively.

We shared our findings with the management team. The manager had requested some of the required work to be completed. One person was being supported to purchase new furniture. The safe storage for cleaning chemicals had been discussed in a recent team meeting and had identified an additional cupboard for cleaning chemicals was required.

Recording of water temperatures when people had baths or showers was inconsistent. This meant the provider could not be assured water temperatures were always within a safe range for people, to ensure there was no risk of scalding.

There were regular checks to ensure the safety of utilities such as gas and electricity. Drills took place to ensure people could be evacuated safely in the event of a fire and checks of fire safety equipment were undertaken. Personal Emergency Evacuation Plans (PEEPs) assessed the level of support people required.

The service had risk assessments which explored how risks in the home environment were managed, this included where people chose to collect items which increased risk in the event of a fire.
 

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.

People were supported by a stable staff team. Several staff had supported people for many years and knew them well.

Staff had received training which enabled them to support people’s needs. Their knowledge and competency were checked through regular supervisions. We found several staff were overdue their annual refresher training in supporting people with behaviours of distress. The manager told us they were in the process of arranging this training. The manager also told us they were in the process of arranging annual appraisals with staff.

There were systems to ensure staffing levels remained appropriate to people’s needs, and to ensure staff working patterns remained safe. The service had identified the need to increase the number of staff supporting people during the night. They were actively recruiting new night staff to join the team and increasing staffing levels.

When staff were recruited, appropriate checks were undertaken to ensure they were safe to provide care and support to people.
People and relatives told us there were enough staff and people were well supported. People’s comments included, “They are great” and “Staff treat me well.” A health and social care professional said, “There is always plenty of staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was mostly clean and odour free. Cleaning schedules and records detailed completion of daily and regular deep cleaning of the service.

People had care plans which recorded how to support them to maintain their own personal hygiene and a clean environment. Some people chose to have a lot of personal belongings leading to an environment which may be hard to keep clean. Where this was the case risk assessments explored how the person could be supported to maintain a clean and safe environment. The manager completed regular infection prevention control audits, and the management team completed regular checks which included cleanliness of the service.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs. Whilst staff knew people’s needs, capacities and preferences with regards to their medicines, improvements were required.

We found several gaps in one person’s topical medicine administration records evidencing this medicine was not being administered as prescribed.
Where a variable dose of a person’s constipation medicine had been prescribed, or when guidance had been provided on what to do if a person declined to take their medicines, we found there was a lack of written guidance for staff to follow.

Specific staff members had responsibility for daily medicines administration. They received training and their competency to administer medicines safely was assessed. They were expected to sign to confirm medication had been administered and signed for correctly. However, handover forms were not always signed and errors we found had not been identified.

Most night staff were not trained to administer people’s medicines. This meant if people required as required medicines at night, for example for pain relief, this would not be available. Following our feedback the service implemented a risk assessment to ensure people could be administered as required medicines during the night if required. The service was in the process of training staff, including night staff to administer people’s medicines.

Staff were aware of STOMP (a national programme aimed at stopping over medication of people with a learning disability and autistic people). People had regular reviews of their medicines, including any as required medicines prescribed for when they experienced behaviours of distress.

When people were being supported to take their prescribed medicines, staff followed people’s preferences and gained their consent before administration. Medicines were stored safely. The temperature of each individual medicine cabinet was regularly recorded. Where medicines errors had been identified, these had been investigated and any lessons learned shared.