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Turning Point - Derby Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 23 October 2020

About the service

Turning Point – Derby supports adults to live as independently as possible who have a learning disability and/or autistic spectrum disorder and whose behaviour may challenge. At the time of our inspection, eleven people were receiving personal care and lived in their own properties or supported living accommodation.

People’s experience of using this service and what we found

People were not always protected from harm, as safeguarding concerns were not always reported or analysed in an effective way. Not all staff had up to date safeguarding training. Medical advice was not consistently sought when injuries occurred.

There were risk assessments in place, however these had not always been updated when changes occurred and not all risks had been identified or mitigated effectively. This included people’s personal evacuation plans not being sufficiently detailed.

Gaps in staff training impacted on quality, safety and individual care needs being effectively and safely met.

The systems and processes in place to assess, manage and review quality and safety were not effective in mitigating and managing risks.

People in the main received their medicines safely. Hand written medicine records did not follow best practice guidance, of having two staff signatures. Whilst action was taken internally when medicine errors occurred, this had not always included a safeguarding referral to the local authority.

There were sufficient staff employed and safe recruitment checks were completed, before staff commenced their employment at the service.

Infection prevention and control best practice guidance had been implemented by the provider, including Covid 19 guidance made available for staff.

Rating at last inspection

The last rating for this service was Outstanding (published 20 February 2018).

The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of risks associated with choking. This inspection examined those risks.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Outstanding to

Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report. The provider has begun to take action to mitigate the risks we found and have provided CQC with an action plan.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Turning Point Derby on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified breaches in relation to safeguarding, risk management, governance and how the provider notified CQC of reportable incidents.

Full information about CQC’s regulatory response to the more serious concerns found during inspections, is added to reports after any representations and appeals have been concluded.

Inspection areas

Safe

Requires improvement

Updated 23 October 2020

The service was not always safe.

Details are in our safe findings below.

Effective

Good

Updated 23 October 2020

Caring

Good

Updated 23 October 2020

Responsive

Outstanding

Updated 23 October 2020

Well-led

Requires improvement

Updated 23 October 2020

The service was not always well-led.

Details are in our safe findings below.