United Response - 66 & 66a Lemsford Road

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 inspection 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.

This service scored 34 (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. Lessons were not always learnt to continually identify and embed good practice. We found that incidents and accidents had not consistently been reviewed or investigated appropriately. Learning was not being consistently captured, shared, or used to demonstrate that learning was being captured, shared, or used to inform improvements in practice. Opportunities for reflection and thematic analysis were not routinely undertaken, which could contribute to repeated occurrences. However, we were informed that the regional manager had recently implemented a weekly review process. This initiative is intended to support better oversight and promote learning across the service. The provider anticipated that, as this process becomes embedded, relevant information and learning would begin to be disseminated more effectively to staff.

The provider did not always work with partner agencies to ensure safe care. Information was not always shared with appropriate professionals in a timely manner which did not allow different services to provider support. For example, the local authority feedback that they did not always get notified of incidents in a timely manner. In addition, where people were going to the day centre there were not clear systems in place with medicine management, which meant the management team could not be assured that the day centre was managing the persons medicines safely. The management team made steps in developing a better communication pathway between partner agencies.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider did not consider the restrictive practices that were in place when supporting people. This meant people had restrictions imposed on them without legal justification or any discussion as to why it was necessary to restrict them.

We found that a number of safeguarding incidents had not been notified to the CQC, including serious concerns such as medication errors, missing funds, and inappropriate handling of a parasitic infestation. These were later submitted retrospectively by the new management team. This lack of governance and failure to monitor the Registered Manager’s performance during this time reflects poor oversight. Similarly, notifications required under regulation had not been consistently submitted, and the provider was unaware of what had been raised until prompted. There was limited evidence of authorised DoLS in place, and while applications had been submitted, the management team did not know their content, which resulted in people being unlawfully restricted. Attempts to clarify this with the local DoLS team were unsuccessful, and no historical documentation was available.

Restrictive practices were observed, including windows screwed shut, locked wardrobes, and food being locked away without clear rationale or best interest decisions. Some restrictions have since been removed following our feedback. The current team had started to review the restrictions in place.

Relatives gave mixed views about the support their family member received with some relatives feeling that the provider offered a safe place for their family to live, whilst others felt they needed more reassurance that their relative was safe. One relative said, “I would say that [family member] has not been kept safe and free from abuse mentally, physically and financially.” Another relative said, “I do feel he is safe. I do worry about his wellbeing though.”

People said they felt safe and happy where they lived. One person said, “I like it here. Staff help me if I feel unwell.”

People were not supported to help understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive. Risk management systems were not sufficiently robust to ensure people’s safety. We found that staff supporting individuals with complex health needs, such as epilepsy, had not received appropriate training, despite being scheduled on rotas. In one case, the risk assessment stated that checks should be completed every 30 minutes, yet daily records showed inconsistent monitoring, with checks occurring hourly or, on occasion, only once per night. This presents a significant risk that had not been identified through internal auditing. Additionally, a choking risk assessment lacked clarity and contained spelling errors, which undermined its reliability. The document failed to provide clear guidance for staff on how to respond to choking incidents. We found discrepancies between the care plan and risk assessment, where the documents did not triangulate. The management team had identified the need for improvements in care planning and risk assessments. However, this lack of triangulation compromised effective risk management.

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.

People were supported to ensure they lived in an environment that met their needs. However, environmental standards required attention, with areas of the home found to be unclean and in need of maintenance, including visible damage to ceilings and kitchen facilities. The management team reported that the responsibility with the housing repairs sit with an external provider, the management team said they are working with them to address these concerns.

Weekly health and safety checks were not consistently being carried out this included fire tests and evacuation drills. Risk assessments for moving and handling, COSHH, infectious diseases, and lone working were all in place.

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. They did not work together well to provide safe care that met people’s individual needs. Staff felt they had the right training to support people. However, records reviewed found that the provider did not make sure there were enough qualified, skilled and experienced staff. Staff training and competency assurance required significant improvement. Although staff reported feeling adequately trained, the evidence provided did not consistently demonstrate that staff were competent to meet the needs of the people they support. For example, one individual communicated using Makaton, yet no staff had received training in this. Learning disability and autism training was delivered via e-learning, however, did not meet the requirements of best practice guidance. The provider acknowledged this and confirmed that improvements were planned, with updated training to be rolled out in the coming months. Medicine competency assessments were being conducted by a manager who had not completed the relevant training, raising concerns about the validity of these assessments. There were also gaps in epilepsy training, with rota records showing staff without appropriate training supporting individuals with this condition across multiple weeks. Epilepsy rescue medication may be required, yet staff on duty were not trained, placing individuals at significant risk. The provider operated a recruitment process; appropriate checks were undertaken to help ensure staff were suitable to work at the service. A disclosure and barring service (DBS) check and satisfactory references had been obtained for all staff before they worked with people. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Recruitment records showed some gaps, and while staff generally felt there were enough team members, concerns were raised about staffing levels. One staff member said, “There is enough, mostly the staff are kind and proactive, and there is teamwork.” Another staff member said, “I think we need more staff, there are 4 people we support, we should have 3 carers, as when 2 staff are supporting people, there are 2 people that are left with no support particularly in the morning it is busy.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had systems in place to assess and manage the risk of infection; however, we found there was a delay in identifying and responding to a parasitic infestation. The manager acknowledged that the issue had been present for some time before action was taken. One member of the management team described a treatment approach that involved returning a person to their bedroom to assess whether the infestation had cleared. This decision did not appear to consider whether it was in the person’s best interest, and parasites were subsequently found to still be present. People have since been moved to alternative rooms, and the provider continued to carry out treatment across the affected areas.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. There was a lack of assurance that one individual was consistently receiving their medication as intended. For example, medicine used to alter a person’s mood was administered on four occasions, yet there was no documented rationale in the daily records to explain why it was given, nor any evidence of steps taken prior to administration. PRN protocols (PRN stands for “pro re nata,” a Latin phrase that translates to “as needed” or “as the situations demands”) were not consistently in place at the time of inspection, although the management team confirmed these have now been implemented. A recent change in the medicines management system has reportedly led to a reduction in medicine errors, which is a positive development. Nonetheless, further assurance was needed to ensure staff were following protocols and documenting decisions appropriately.