Gowlands

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.

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 systems in place for recording individual incidents and accidents. Staff listened to people and acted upon any concerns relating to people’s safety. However, the provider had not always ensured all incidents were robustly monitored and reviewed to demonstrate actions taken. This meant it was not always clear how lessons were being learnt to mitigate future risks and ensure good practices were embedded.

Following our feedback the provider responded promptly, confirming they had implemented a new monthly process for reviewing incidents to clearly evidence actions taken and learning identified.

The provider worked well with people and healthcare partners to establish and maintain safe systems of care. They shared information appropriately and made sure there was continuity in people’s care. When people came into the service for respite, the provider liaised with their relatives and the relevant health professionals to ensure people’s transitions to and from the service were managed safely.

The provider had a safeguarding policy and process in place for staff and leaders to follow. Where safeguarding notifications had been raised, the registered manager had completed investigations appropriately and shared outcomes and learning. Staff had received safeguarding training and knew how to raise concerns.

However, the provider’s processes for reviewing incidents were not always robust and this meant we were not assured potential concerns were always identified and investigated. For example, we found incident reports relating to people experiencing distress which did not provide sufficient detail about what had happened or how staff had responded to minimise distress and ensure appropriate support was provided.

Following our feedback, the provider updated their processes for reviewing incidents and evidenced how any potential safeguarding concerns would be promptly identified and investigated.

The provider had a process in place for assessing and managing risks to people’s safety. However, whilst we found some people had detailed risk assessment guidelines in place, this was not consistent, and we found some risk assessments did not contain sufficient detail.

Despite these concerns, all staff we spoke with were able to tell us about people’s personalised risks and how these were monitored to ensure people remained safe. Staff also told us the registered manager and senior support workers were available to provide support and guidance if required.

Following our feedback, the provider responded promptly to confirm they had updated all relevant risk assessments to ensure they contained detailed guidance about how to support people safely.

The provider had processes in place to detected and control potential risks in the care environment. However, during the inspection we found unsecured wardrobes which posed a potential risk of falling. The provider told us the wardrobes were usually secured to the wall and had only been unattached to enable redecoration. During the site visit, the registered manager immediately arranged for the wardrobes to be resecured appropriately and updated their environmental checklists.

Maintenance and equipment checks were in place. However, the provider’s timetable for health and safety checks and inspections was not up to date. This meant it was difficult to see when checks and safety inspections had been completed and when they were next due.

Following the site visit, the provider confirmed all health and safety checks were in date and produced an updated health and safety timetable to evidence completion and due dates.

The provider made sure there were enough staff available to meet people’s needs and preferences. Staff knew people well and were consistent in their support.

Processes were in place to provide staff with relevant training to meet the requirements of their role and the specialised support needs of people staying in the service. However, at the time of the inspection, the provider’s records evidenced some mandatory staff training had expired.

The provider told us they reviewed staff training monthly and checked staff with appropriate, specialised training were on shift when required. Following our feedback, the provider confirmed staff specialisms would now be highlighted on the rota to clearly identify staff on shift with relevant skills and training. The provider also confirmed all out of date training was now scheduled.

Recruitment processes were in place to check staff were safely employed. We identified some gaps in the screening of applicant’s employment history. The provider responded promptly, updating their recruitment screening tool to ensure more detailed checks were incorporated.

The provider assessed and managed the risk of infection and detected and controlled the risk of it spreading. The service had an infection prevention and control policy in place for staff to follow and relevant training and resources were available to support staff to follow good hygiene practices.

People’s medicines and treatments were safe and met their needs. During the inspection we observed staff supporting people to take their medicines safely. People’s medicines records were accurate and up to date and staff had recorded the administration of medicines appropriately. The provider had a medicines policy in place and completed regular medicines audits to monitor staff practices and identify any concerns promptly.