43 Station 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 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 in breach of legal regulation in relation to safe care and treatment and good governance.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty.

Staff understood how to report accidents and incidents. Systems were in place to ensure these were reviewed and acted upon.These events were also monitored across services on a local level and discussed weekly during leadership meetings to continually identify and embed good practice.Team meetings with staff were used to discuss these incidents. Managers used this opportunity to speak with staff about internal procedures and changes in processes to protect people from harm.

The provider worked with healthcare partners to establish safe systems of care. However, these systems were not always effectively used or monitored to ensure people’s ongoing safety. People were able to see health care professionals when they needed to.

Records showed when people’s needs changed, referrals were made to services to ensure they received the support they required. However, we saw people were provided with food that included larger textures than advised and may have placed people at a risk of choking.

Relatives told us they were not always kept informed of outcomes. One relative told us, “I haven't been told [there] are changes in [person’s] medication. They don't keep me up to date”.
Managers told us they receive profiles of people who would like to move into the service and would arrange an initial meeting to ensure staff could meet their needs. They told us they would arrange a series of visits to support a smooth and planned transition into the service.

Staff told us that before one person moved into the service, they gathered information by speaking with staff who had worked with the person at their previous service.This helped the provider understand the risks to people across their care journey and ensured information about people was available to help manage any risks in a proactive and effective way.

The provider did not consistently engage with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Mental capacity assessments and best interest decisions were not always decision specific or recorded in line with the Mental Capacity Act. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the capacity to do so themselves. The provider did not always demonstrate how best‑interest decisions had been made or formally recorded, which limited assurance that people were consistently protected from potential risk. The manager acknowledged these gaps and told us they had started reviewing and updating relevant documentation.

Staff were focused on safeguarding people and supporting them to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They demonstrated an understanding of the MCA and their responsibilities to support people to make decisions wherever possible. Staff had completed safeguarding and whistleblowing training and understood how to raise concerns about poor practice with managers. We observed that people appeared to be treated well and were appropriately cared for.

The provider had made Deprivation of Liberty Safeguards (DoLS) applications where required to ensure people were lawfully supported when restrictions were needed to keep them safe.

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.

Support plans had detailed information and strategies to guide staff in supporting people safely. The provider had completed risk reviews to highlight potential concerns. These included people’s individual risks of choking and best practice guidance to reduce the risk of harm. Staff told us how they followed recommended guidelines, although records showed that people were sometimes given food that did not meet these requirements.

People at risk of emotional distress or anxiety had appropriate support plans, which included descriptions for different levels of concern and guidance on how staff should respond. The manager told us they did not use restraint and staff received training on supporting those experiencing heightened emotional responses. Managers told us they had collated information in support plans from observing people and speaking with staff to better understand potential triggers and factors that could lead to emotional distress.

The provider detected and controlled potential risks in the care environment. Equipment, facilities and technology were used effectively to support the delivery of safe care.

The provider undertook regular checks of the environment and worked collaboratively with external partners, such as the fire and rescue service, to help ensure people were safe. The provider had clear systems in place to ensure routine servicing and maintenance of equipment, and where recommendations were made these were actioned and escalated internally in line with organisational policies and procedures. Fire safety equipment had been checked by suitably qualified persons to ensure it would be effective in the event of an emergency.

People had person‑centred emergency evacuation plans in place which contained clear and relevant information to support a safe response in the event of an emergency.

The provider made sure there were sufficient qualified and experienced staff, although staff did not always have the skills needed to ensure people had flexibility and choice for how they wanted to spend their time.

The provider used systems to calculate staffing numbers to meet people’s needs. However, staff told us that at weekends they were often only able to travel locally with people, as there were no staff members who could drive. Records all showed that people did not often go out on weekends due to this. Since the assessment, the provider had identified this and has advertised to recruit more staff who are able to drive.

All staff members were hired following safe procedures, such as conducting reference checks and DBS screenings. Staff were provided with a detailed induction and ongoing training. One staff member said, “I had my induction with [manager] and they made sure everything was clear, including all the policies”.

The provider received profiles for agency staff and completed an induction with each person prior to them starting to work in the service.

Staff received effective support, supervision, and development. The provider ensured staff compliance with mandatory training. When training was due the provider ensured staff were booked onto upcoming courses. Staff completed training relevant to the setting and to meet the needs of people using the service. A number of staff were engaged in health and social care apprenticeship programmes.

The provider assessed and managed the risk of infection and had effective measures in place to prevent it from spreading.

Staff were allocated daily tasks to maintain a clean and tidy environment. The provider carried out regular checks of the environment and equipment. One relative told us, “It’s always tidy, well decorated and [person’s] room is nice.”

Personal protective equipment was readily available in communal areas, and we observed staff using this appropriately when supporting people. Handwashing facilities were available throughout the service, supported by clear visual guidance on best practice for hand hygiene.

The provider did not always make sure that medicines and treatments were safe and met people’s needs and preferences.
The provider had systems and processes in place to administer medicines safely, staff were not always following these. There were gaps in records where staff were not signing for administration and stock counts. Some medicines did not have the actual dose of the medicine staff had given. Despite regular audits of these records, errors continued to occur, indicating the audit process was not effective in identifying and preventing repeated medicines errors. This meant people were at risk of receiving medicine incorrectly or unsafely.

The temperature of the medicine storage room were monitored, although was often recorded below a safe range. This had not been escalated through monitoring. The manager took prompt action and has implemented processes to prevent recurrence.

Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation, pain, and anxiety. There was guidance in support plans and protocols in place for these medicines to be administered correctly and safely.