Nevin 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 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 in breach of legal regulation in relation to the environment, the Mental Capacity Act and staff training.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not learnt to continually identify and embed good practice. The culture within the service was not consistently focused on safety and learning. There was a system in place for recording and analysing incidents. However, it was not always clear how lessons were learnt from these and how these could be used to drive improvements to the service or people who use the service. For example, the service was working with the local authority to make improvements. An action plan devised in June 2024 by the local authority stated that specific diagnosis for a person should be added to their care plan and reviewed with their next of kin. However,this had not been actioned at the time of our inspection. We found a persons mental health diagnosis was not documented in their care records. We also found points of learning around the environment had not been embedded. For example, the interim manager told us that staff had been informed to keep laundry and staff room doors closed at all times. However, both doors were open and accessible to people who lived at the property, placing them at risk of harm.

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. People had individual hospital passports and staff supported people to medical appointments.

The provider sometimes 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.Relatives told us they felt their loved ones were safe. Not all staff had received training in safeguarding and protecting people from abuse. When we spoke to some staff, they had limited knowledge of safeguarding and did not fully identify their responsibility of appropriately recording potential or actual safeguarding incidents. However, all staff stated they would report abuse. For example, one staff member told us, “I have to inform my manager”. The interim manager and staff had limited knowledge in following good practice when it came to preventing someone from leaving the home for their own safety. For example, we found one person was deprived of their liberty unlawfully as they did not have a Deprivation of Liberty Safeguards in place.

The service did not always work well with people to understand and manage risks. They 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’s care plans highlighted their needs and strategies for supporting them. While staff were able to tell us information around the cause of people’s distress. People’s care plans did not detail clearly contain these details. [JM1]We also found care plans were not reviewed with the person or those important to them. For example, one person was identified as a risk of leaving the service unaccompanied, but staff did not have consistent information to ensure if this happened, they managed this safely.

The service 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. We identified multiple areas of risk with the environment for people at Nevin House. For example, not all windows had restrictors to reduce the risk of people falling from height. We also found not all hot water pipes were covered appropriately to reduce risk of scalding. The garden of the property was unsafe, and a person’s room had a wardrobe which was not secured to the wall. We raised concerns around the environment with the interim manager who began to make improvements immediately to reduce the risk to people.

While relatives told us they felt there were enough staff on shift, people’s choices were restricted at times due to staffing levels which meant people were not always able to go out into the community when they chose to. Staff had not received training in supporting people with a learning disability and autistic people or equality, diversity and inclusion. This placed people at risk of not receiving inclusive care in line with their needs. Staff did not receive regular supervision; however, told us management were approachable out of hours should they need support and guidance. Staff were recruited safely and received an induction prior to commencing their roles.

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. There were areas of the environment which had patches of mould and required attention. These had been identified by an external partner’s audit in June 2024 and whilst the provider assured us action had been taken, improvements had not been sustained as the concerns were ongoing at this inspection. There was also chipped paint in high frequency touch points which were not identified during the provider’s own audits. Staff demonstrated knowledge of good hygiene standards including the use of personal protective equipment to prevent the spread of infection. Staff had received infection prevention and food hygiene training.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider’s quality assurance checks had not been effective in identifying areas for improvement in relation to the safe administration of people’s medicines. Staff had received medication training, and competency assessments in administrating medication. However, staff did not always have sufficient guidance around people’s ‘as required’ medicines. For example, medicines provided by family members to ensure staff understood what these medicines were for, when to administer them and the signs to look out for if the medication was effective. Medicines were not always stored safely. For example, we found unlabelled medicine not belonging to a person in their medicine cabinet. This placed them at risk of harm of taking a medicine they were not prescribed.