Archived: OSJCT Buckland Court

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 service was still in breach of the legal regulation in relation to safe care and treatment. We have issued an action plan request to address these issues.

This service scored 53 (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 provider had a system to record and report incidents and accidents, but these were not always reviewed and acted upon by the registered manager. For example, 1 person’s care notes demonstrated there were gaps in the recording of planned night-time checks. Leaders did not appropriately respond to these gaps and lessons had not been learnt.

However, staff attended regular training and refresher courses. These were a mixture of face to face and e-learning. Staff said the training was good and informative. Staff also told us the training had enabled them to understand the importance of reporting incidents and to learn from them.

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. One relative shared they had to fill in a “comprehensive” form relating to likes and dislikes, allergies and what foods their family member enjoyed. Other relatives felt the move into the service for their family member had gone well and the support from staff had been good.

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. People told us they felt safe in the service and were confident they could discuss any concerns with staff. Relatives shared they felt people were supported safely. Staff had received appropriate training and could identify what steps they should take if they identified or were told of any safeguarding concerns.

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

People were not always being supported well in relation to risk-taking when making choices about leaving the service independently. People told us they were never “allowed out”. We raised this with the registered manager during our first onsite visit, who confirmed people did not go out independently or with staff support from the service, even when they had capacity to make that choice, but could not explain why they did not support people to do this.

The provider did not always detect and control potential risks in the care environment. The provider did not consistently assess, monitor or mitigate risks relating to the safety of the environment. Systems were not effective to ensure equipment, facilities and access points supported the delivery of safe care. For example, a fire exit door was observed to have been left open throughout the day during our first onsite visit. We were told this door was regularly used by all staff, to access an external smoking area. However, several people living at the service had care plans which identified them as at risk of leaving the building unsupervised. One person’s care plan specifically stated all fire doors should always remain locked due to this risk. By not following this action, people were at increased risk of harm.

One person had a risk assessment identifying their risk of leaving the service without the knowledge of staff. To mitigate this risk the service had recorded they would have window restrictors on all windows. However, we observed a bathroom window was missing a window restrictor. The bathroom window opened wide enough for a person to climb through to leave the home. This meant the provider could not be assured they were protecting people from the risk of harm. On the second day of the inspection, we saw window restrictors had been added to the bathroom window and other windows within the service.

In one bedroom, we observed an extension lead was taped to the floor, which had become detached. This not only created a trip hazard but also compromised both cleanliness and infection control within the room.

Furthermore, the service had a health and safety audit in 2024 but some of the recommended actions such as replacing fire door were not completed in a timely way. This put people at unnecessary risk of harm in the event of 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.

The provider had systems to support safe staffing levels, including the use of a dependency tool to determine appropriate staffing numbers. Where gaps occurred on the rota, bank staff were used to maintain safe cover. The registered manager described how they had challenged the provider to uphold staffing levels, and said the provider was responsive and supportive in meeting the service’s needs.

People and their relatives gave generally positive feedback about staffing levels, although some relatives said more staff would be nice to give people more time to talk.

New staff completed an induction when they joined the service, and all staff received refresher training as needed. The provider’s in-house trainer described examples of additional training that had been introduced in response to feedback from external professionals, this included required training on supporting people with a learning disability and autistic people. .

Staff received regular supervision with their line manager in line with the provider’s policy, during which they could reflect on their role and identify any training or development needs.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. During our first onsite visit, it was noted in a bathroom, there was evidence of incomplete maintenance work; for example, tiles surrounding the sink were broken and the area appeared to be in a poor state of repair. As of result, this did not allow for effective infection prevention and control practices to be maintained with effective cleaning of surfaces.

We raised concerns with the home manager and senior staff during our first onsite visit regarding a strong odour present throughout the service. During our second onsite visit, 8 days later, efforts had been made to eliminate the odour. However, it was still present in several areas. The odour indicated cleaning practices and infection control measures were not effective to ensure such an odour didn’t occur in the first place. However, the new interim manager shared plans of how they intended to ensure the odour was eliminated completely from the service, but a timescale of completion was not yet achieved.

Many areas of the service were noted to be visibly unclean and dirty. There were no cleaning schedules available to review, and it was unclear when spaces had last been cleaned. For example, bathrooms, including toilets, were noted to not be clean. One person’s riser recliner chair had an old staining down the arm front. In the kitchen areas, cupboards and surfaces were noted to be stained and visibly dirty, and a water cooler in the main dining area was also unclean with fluid stains and dust over it. These conditions placed people at serious risk of exposure to infection due to poor cleanliness levels.

However, staff did have access to personal protective equipment (PPE), and we observed staff appropriately washing hands and using PPE during care tasks. Furthermore there had been no recent concerns relating to infection management within the home.

The provider did not make sure that medicines and treatments were safe and met people’s needs.

There had been a serious incident recently where medicines had not been appropriately booked in by staff. This issue had not been identified by leaders or staff for a week resulting in one person being administered double their prescribed dose. This incident led to the person being hospitalised. However, the provider was able to demonstrate it had taken appropriate action including a lessons learnt meeting and retraining for staff involved to reduce the risk of this incident happening again.

However, medicines were stored safely, and storage room temperatures were regularly taken. Staff attended medicine management training as part of the provider’s mandatory training and then further refresher courses. Where medicine errors had occurred, appropriate action had been taken to address these to ensure no recurrence happened.