Gleberry Support Hinckley

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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 63 (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. Staff listened to concerns about safety and investigated and reported safety events, however lessons were not always learnt to continually identify and embed good practice.

There were some areas where incident recording and follow up could be strengthened

Immediate action was taken where required, including contacting emergency services and relatives. However, records for 2 people did not demonstrate unexplained bruising had been explored or followed up. This meant opportunities to identify any further action needed and learn from incidents may have been missed.

There was evidence of learning in some areas. For example, medicine stock monitoring had been introduced for one person to strengthen oversight of their medicines.

People and relatives told us they were confident the registered manager would respond to incidents and concerns. Staff understood their responsibilities to record and report incidents. The registered manager assured us incident records would be reviewed to ensure appropriate follow up was recorded and any learning identified and acted on.

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 and relatives told us pre-assessments were completed before care began, and we saw evidence that initial assessments and care plans were in place to support safe care.

The registered manager described how people’s needs were reviewed when they moved between services. Following hospital discharge, information was reviewed and people and families were consulted to identify any changes to medicines, mobility, eating and drinking or swallowing needs, with care plans updated accordingly. For people new to the service, the registered manager told us assessments were completed in hospital and in the person’s home before care commenced.

The provider 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. The provider shared concerns quickly and appropriately.

People and relatives described feeling safe and having confidence in the staff who supported them. One person told us, “I can pick up the phone if I need them that’s the safety net, there is always someone there.” A relative said, “I am familiar with all the staff and trust them all. I can leave them with her and have peace of mind.”

Staff demonstrated a clear understanding of safeguarding and described their responsibility to protect people from abuse, harm and neglect, uphold their rights and dignity, and ensure they were listened to. Staff also understood the importance of recognising potential indicators of concern. One staff member explained they would be alert to changes in a person’s behaviour and would “Report it to the manager.”

However, on 1 occasion, records showed unexplained bruising which could have been explored further to understand the possible cause and determine whether any further action was required.

Safeguarding policies and procedures were in place and staff had undertaken safeguarding training. At the time of our inspection, no person had been granted or an application made to the Court of Protection for a Community Deprivation of Liberty Safeguard (DoLS). This occurs when a person lacks capacity to consent to their care and treatment. It protects people who can’t protect themselves.

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.

Risks to people were identified, although care records did not always contain sufficiently detailed person specific guidance. One person’s records identified Parkinson’s disease and dementia but contained limited information about how these conditions affected them and their individual support needs.

Another person’s records identified they had epilepsy, although they had not experienced a seizure for a significant period. Guidance about how staff should recognise and respond to a seizure was limited. Staff had received relevant training; however, clearer instructions were needed when care was provided without family members present.

The registered manager acknowledged these gaps and assured us the relevant risk assessments and care records would be updated to include clearer, person specific guidance.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental risk assessments contained relevant safety information, including key safe details and the location of gas meters. Some sections relating to environmental risks, such as trips hazards and loose rugs had not been fully completed. The provider told us these checks had been completed and no concerns identified. The registered manager assured us this would be clearly documented going forward.

The provider did not always make sure staffing arrangements were sufficient to consistently provide care as planned. They did make sure staff received support, supervision and development. Staff worked together to meet people’s individual needs.

Whilst staff we spoke with did not raise concerns about their working hours, staffing arrangements did not always support staff to work within the Working Time Regulations, as some staff had limited breaks between the end of one shift and the start of the next.

Staff were not always allocated sufficient travel time between care calls, with some calls scheduled consecutively without travel time between them. We found some people did not receive the full duration of their planned care calls because staff left early to travel to their next call. Some staff we spoke with confirmed this occurred. This meant staffing arrangements did not always ensure people received care for the planned duration.

We discussed this with the registered manager, who assured us they would review staff working hours, breaks between shifts and the allocation of travel time between call.

Despite these findings, people and relatives we spoke with did not raise concerns about the timing or duration of their care calls.

Staff received training relevant to the needs of the people they supported and completed an induction when they joined the service. Staff also received regular supervision and annual appraisals. Safe recruitment processes were followed, including obtaining references and Disclosure and Barring Service (DBS) checks. DBS checks help employers make safer recruitment decisions and prevent unsuitable people from working with people who use services.

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.

People and their relatives told us staff wore appropriate Personal Protective Equipment (PPE). Staff were able to describe how they reduced the risk of infection during care delivery and told us PPE was collected from the office and was always readily available.

Staff had completed infection prevention and control (IPC) training. The provider also carried out observed practice checks to ensure staff used PPE correctly and followed IPC procedures when required.

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.

Some medicine records and protocols did not contain sufficient information to guide staff about how and when medicines should be administered. For one person, guidance did not clearly record the specific timing requirements for a medicine in relation to food, and daily records did not contain enough detail to establish whether these instructions had consistently been followed. Some protocols for medicines prescribed to be taken when required (PRN) also lacked clear guidance about when they should be administered.

Records for transdermal patches were not always adequately detailed. Although patch rotation guidance was available, staff did not consistently record where patches had been applied or, where required, whether application sites had been checked for skin irritation.

We discussed these findings with the provider, who assured us medicines guidance and recording would be reviewed and action taken to address the and action taken to address the shortfalls. This included ensuring staff had clear information about when medicines should be administered and strengthening records for transdermal patches.

Despite these findings, people and relatives raised no concerns about the management of medicines and told us they felt medicines were administered safely. Electronic medicines administration records were in place, staff recorded the application of topical medicines, and the provider monitored medicine stock levels to help ensure supplies were maintained.