Aspire Hub 1

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 people’s safe care and treatment.

This service scored 41 (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 based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were recorded; however, actions were not always followed up. For example, there were incidents where the provider had recorded “incident to be discussed in staff meetings and staff supervisions”. We reviewed meeting minutes and supervision records, and this had not always been done. One staff member had made 5 medication errors within 12 months, and their supervision record advised further training was required however, this training did not occur therefore lessons were not learnt.

Oversight to identify trends and themes was not robust. In some instances, records did not include the staff member’s name who was involved in the incident and the date the incidents happened to identify common themes.

Some staff told us they were not informed of actions taken when they had reported incidents. Comments included, “We report concerns to management about neglect of people, and they don’t do anything. They hardly ever feedback about incidents or trends” and “We don’t hear back about incidents we report. We fill out a form and give it to management and they take over. I don’t know what happens after that.” One relative stated, “I report things they don’t address them.”

The service worked in partnership with a range of health and social care professionals, so people’s current and changing needs were met. Staff were clear who to report concerns to so that referrals could be made.

Poor records in some care plans increased the risk of care pathways and transitions not being safe as the information being shared may not be accurate. We received feedback from the local authority who told us information was not always robust.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. Some people, relatives and staff we spoke with during our assessment did not feel adequate measures were in place to keep people safe. For example, one person was not comfortable around another person living in the service and therefore avoided communal areas following incidents of aggression. Comments from people and relatives included, “There were incidents when a resident pushed (relative’s name) over, Police were called and took statements but nothing was done for the safety of residents and carers” and “I want [Name] to live in a safe environment in their own flat, [Name] has a right to wander in the communal area, [Name] is not safe with [other residents Name] and the others aren’t either.” Some staff told us safeguarding incidents were not always managed to ensure risks were mitigated. For example, one staff member said, “I have sent so many emails to the management team about concerns and hardly any have been responded to.” During our review of safeguarding, we found records relating to incidents were not always accurate or clear to determine actions taken and lessons learnt.

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 assessments were not always robust for example, one person did not have a protocol attached to their risk assessment to manage their infection control risks. We asked staff to tell us about the protocol, and they were unaware of this. Another person’s care plan directed staff to follow the persons positive behavioural support plan however, this could not be located during the assessment.

Staff worked with people who at times showed aggression. Some staff had completed their positive behaviour support and physical interventions training whilst others required refresher training. Following our feedback the provider booked staff onto refresher courses. Fire safety checks were not up to date. For example, we were only provided with one fire drill for the service which meant not all staff had completed a fire drill to ensure people could be safely evacuated. The provider told us they have arranged for this to be completed.

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. During our walk around of the communal areas we found topical medicines had been left in bathrooms which people had access to. The communal lounges were not clean with stains and broken furniture. Communal bathrooms had furniture stored in them. One lounge had a person’s wardrobe with their clothes in which had not been secured to the wall and therefore a safety risk to others using the lounge. Some people using the service and their relatives told us they did not always feel communal areas were safe due to other service users.

Whilst the provider ensured there were enough qualified, skilled and experienced staff, who worked well together to ensure people’s needs were met, staff did not always receive continuously effective support. For example, supervisions were not always completed and some staff told us they did not feel supported. Comments included, “If you say you are stressed out to management, they don’t ask you why and don’t look after staff” and “I get my supervision from support leaders usually, but we have had a few leave, so I’ve not had one in a while.”

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. The service had an annual audit completed; however, this had not identified the issues we found on assessment. For example, we found used mops next to clean laundry, used gloves on the floor and dirt on the walls and table within the communal areas. Staff had completed their infection prevention and control training and were knowledgeable about infection and prevention procedures. Staff told us they had access to personal protective equipment and that this was always worn when needed.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were recorded; however, actions were not always followed up. For example, there were incidents where the provider had recorded “incident to be discussed in staff meetings and staff supervisions”. We reviewed meeting minutes and supervision records, and this had not always been done. One staff member had made 5 medication errors within 12 months, and their supervision record advised further training was required however, this training did not occur therefore lessons were not learnt.

Oversight to identify trends and themes was not robust. In some instances, records did not include the staff member’s name who was involved in the incident and the date the incidents happened to identify common themes.

Some staff told us they were not informed of actions taken when they had reported incidents. Comments included, “We report concerns to management about neglect of people, and they don’t do anything. They hardly ever feedback about incidents or trends” and “We don’t hear back about incidents we report. We fill out a form and give it to management and they take over. I don’t know what happens after that.” One relative stated, “I report things they don’t address them.”