Magdalen Close Hostel

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 assessing potential safety risks.

This service scored 56 (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. Whilst staff listened to individual concerns about safety, the service did not always investigate and report safety events in a way which would support a wider learning culture. Lessons were not always learnt to continually identify and embed good practice. Staff acted when incidents occurred, but learning was not consistently analysed or shared across the team. We found there was no formal analysis of trends being reviewed from incidents, falls, and safeguarding, which limited opportunities to improve outcomes. Staff were open and willing to reflect on practice, yet systems to support organisational learning were inconsistent. For example, incident records lacked clear review, and there were no formal debriefs after events, meaning lessons could be missed. Leaders acknowledged these gaps and had begun work to strengthen oversight and introduce more structured learning processes.

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 were generally supported safely as they moved through internal pathways and external services, and staff ensured day-to-day continuity of care. Staff coordinated well with professionals and ensured people accessed health appointments and specialist advice when needed. A professional who worked with the service told us, “Nothing is never too much trouble when communicating with Magdalen Court Hostel when I am seeking information or to complete care plan reviews. Information that I require is always shared promptly and I find it to be accurate.” People moving on from the service were supported with planning, although information from external partners was not always communicated promptly. The provider told us they would follow this up for future working practices. Some care documentation required clearer updates during periods of transition, but overall people received consistent support.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did not always share concerns quickly and appropriately with the CQC. Safeguarding matters were managed well on an individual basis, with appropriate actions taken and information shared with the local authority. Staff understood how to recognise and report safeguarding issues, and people were protected from immediate harm. However, whilst there had been very few incidents, we found safeguarding issues were not analysed for patterns or themes. This meant leaders could not demonstrate learning or improvement over time. Additionally, statutory notifications of abuse had not been submitted to the CQC as required, which limited regulatory oversight. The registered manager submitted statutory notifications retrospectively during the inspection period. Despite this, relatives expressed confidence in the safety of their family members. One relative told us, “We definitely feel [person] is safe in the home.” They also described how the service responded to a safeguarding event, stating, “The outcome is unsubstantiated. Additional measures have been put in place and recommendations. There are ongoing checks.”

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. Risk management arrangements were not sufficiently robust or comprehensive. Important risks were not always assessed or reviewed, and several assessments lacked the detail needed to guide staff practice. For example, 1 person who was known to be unsteady on their feet had recently fallen, yet there was no falls risk assessment in place. Similar omissions were found in relation to choking, asthma and diabetes, where known risks were either missing from assessments or recorded only in very general terms. These gaps meant staff did not have consistent or reliable written information to support safe decision making, increasing the likelihood that risks could be overlooked or managed inconsistently. After the inspection, the registered manager updated these risk assessments straight away. Care planning and risk assessment documents were referred to by staff day-to-day in hard copy paper files. Work had begun to update and transfer information to a new electronic system, but this was at an early stage. Whilst a familiar staff team knew people well, improvements were required to ensure all known risks were fully assessed, accurately documented and subject to regular review to ensure people received safe and consistent care.

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. Environmental safety systems were not consistently effective. Whilst routine safety checks were being completed on the environment, it was not always clear what action had been taken as a result. There was a lack of clarity in relation to the fire risk assessment held on site, including when reviews had taken place and by who. After the inspection, the registered manager confirmed an in-date review had been undertaken by a competent external company. Night staff had never participated in a night-time fire drill, meaning their understanding of evacuation roles and response procedures had not been practically tested. This increased the risk that staff may not respond safely in an emergency. The registered manager confirmed they would introduce additional fire drills straight away. Personal Emergency Evacuation Plans (PEEPs) were generic and did not fully reflect people’s individual risks, for example in relation to their mobility or how they might express distress in a situation such as a fire. Some people were using paraffin based emollient creams, which are flammable, but there were no risk assessments in place, and this was not referenced in fire safety documentation. Leaders confirmed they would update risk assessments in this area, and this was provided after our inspection.

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. However, we identified shortfalls in the governance of recruitment files, as systems were disjointed and no audits carried out. The provider operated a centralised recruitment process, which meant the registered manager did not hold complete staff records on site. As many pre-employment documents were controlled by the provider’s central recruitment team, the service could not evidence that safe recruitment checks had been completed before staff started work. Although the registered manager assured us compliance checks were done centrally, as on-site management did not have access to key information such as employment history, this meant they could not reliably complete areas they were responsible for in the process, such as checking references. These system issues which could lead to gaps and omissions had not been identified and addressed. The provider told us they would raise this with HR to ensure systems were more fit for purpose going forwards. We also received evidence of safe recruitment checks after the inspection. Despite these governance weaknesses, staffing levels met people’s needs and the team was longstanding, committed and flexible. A relative told us, “There are enough staff and they’re really good. Really well trained. They’re all very committed and caring.” Another person’s relative said, “There’s enough staff, weekends and weekdays, no problems at all.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service maintained a clean and hygienic environment, and infection prevention and control (IPC) measures were effective. Staff followed safe practices, including appropriate use of personal protective equipment, regular cleaning routines and good hand hygiene. The premises were tidy, and shared living areas were well maintained. A relative said, “It’s clean and tidy and generally well decorated.” IPC audits were carried out and mostly up to date, although some records required some improvements to ensure full consistency. There was a dedicated domestic cleaning team, who supported staff to ensure good standards were met. A staff member said, “Our domestics are very good.” People also carried out their own cleaning and household chores where they were able and chose to do so, to promote their independence. Practices seen during the inspection showed that people were protected from the risks of infection and that staff took appropriate action to maintain a safe and hygienic environment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Records did not always show why ‘as-needed’ medicines to support anxiety or distress were administered or whether they were effective. We also identified 'as‑needed’ medicine protocols lacked essential detail, including when the medicine should be used, maximum dosages and what staff should consider before giving it. Information relating to covert administration was not always clear in showing this was the least restrictive option. We also identified 1 person’s care plan which appeared to show medicine related decisions could be made by staff rather than clinicians. The registered manager assured us this was not the case and confirmed this document would be updated. However, these gaps limited the provider’s ability to demonstrate safe, consistent and person-centred medicines practice. Despite these concerns, we found medicines were generally given safely and as prescribed, medication administration records (MARs) were completed accurately, and all medicines balances checked by inspectors were correct. Relatives expressed confidence in how medicines and healthcare support were managed. One relative told us, “[Person’s] meds are good. They’re on top of that.” Another relative said, “We’re very confident with the care [person] receives.”