Magda

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated Requires Improvement.

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 regulation for people’s safe care and treatment.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Quality Statement Score:3

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were 19 reported incidents in the last 12 months and out of these, 1 was rated as serious. Incidents included clients relapsing whilst still at the service and incidents where clients needed mental health crisis support. There were no specific themes or trends.

All staff knew what incidents to report and how to report them and staff reported all incidents that they should report. Incidents were investigated thoroughly, and actions were taken where concerns were identified.

Staff understood the duty of candour. They were open and transparent, and gave clients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. Managers shared feedback during staff meetings and emails. Staff met to discuss that feedback. There was evidence that changes had been made as a result of feedback. For example, managers reviewed boundaries training following an incident where a member of the staff team had not maintained appropriate boundaries.

Staff were debriefed and received support after a serious incident.

We scored the service as 3. The evidence showed a good standard. The service 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.

The service’s referral and admission processes ensured that all essential information about the client was received to determine if the client’s needs could safely be met.

Staff involved all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. The service had access to a limited number of aftercare flats and liaised with other services to ensure aftercare plans were in place including housing and other ongoing support. Staff also had plans in place should a client leave treatment unexpectedly, although these did not always contain enough detail to support staff in the event of this occurring.

We scored the service as 2. The evidence showed some shortfalls. The service 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 or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not identify or explore all safeguarding concerns quickly and appropriately.

All staff were trained in adult and children safeguarding at an appropriate level, knew how to make a safeguarding alert, and did that when appropriate. Staff had made 12 safeguarding referrals in the past 12 months.

However, documentation did not always evidence exploration into safeguarding concerns. There was no box on the risk management plan template to specifically record safeguarding concerns, which meant staff were not prompted to consider or record safeguarding concerns. Records did not always contain evidence that potential safeguarding concerns identified at assessment had been explored or mitigated. For example, staff had not always recorded details of actions being taken to ensure children were being kept safe.

Staff could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The service had up to date safeguarding policies and procedures for children and adults and the service had a designated safeguarding lead whose information was included in the policy.

Children were not permitted to visit the service, however staff supported service users to have contact with their children off site.

Mental Capacity Act

100% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. For example, staff understood that capacity could be temporarily affected through the consumption of alcohol and monitored this carefully when a client relapsed.

The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards (DoLS). Staff were aware of the policy and had access to it. Staff knew where to get advice from within the organisation regarding the Mental Capacity Act.

Staff took all practical steps to enable clients to make their own decisions. For clients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They 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.

We reviewed 4 risk assessment plans during our inspection. Staff involved clients in care planning and risk assessments. Risk assessments were completed with clients and clients were aware of what was in their risk management plans and care plans and had been offered copies of them. Risk management plans were up to date and were updated when needed.

However, risk management plans did not reference all concerns identified within assessments. The risk management template did not contain reference to mental health concerns or safeguarding and we found these were not always explored or mitigated within the documentation. For example, there was not always evidence that potential safeguarding concerns identified during assessment had not been reviewed within risk assessments. Concerns mitigated within the risk management plan were not always detailed. For example, one record identified a client had a heart condition but there was no information in the risk management plan about what to do if the client was suspected of having a heart attack or how this may present for the client.

Staff enabled clients to give feedback on the service they received via weekly community meetings and surveys. Staff ensured that clients could access advocacy if they needed to access this.

We scored the service as 2. The evidence showed some shortfalls. The service 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.

Staff carried out regular risk assessments of the care environment. The service had up to date fire risk assessments and staff carried out regular fire drills. Staff carried out regular environmental checks, and these were up to date. However, there was a cluttered conservatory attached to one room which meant it would have been difficult for clients to get out of the building easily in the event of a fire, if they needed to use this route.

An audit had been completed which identified ligature anchor points and the service had ligature cutters and there was guidance on how to use these. However, the guidance was complicated, and staff had not received any face-to-face training to help them understand the practicalities of dealing with a person who had ligatured. Following our inspection, the provider introduced further training on managing ligatures, into the staff induction, in order to ensure staff competency in this area. Ligature risks were mitigated through individual client support. However, there was no overarching policy with regards to ligature risk management.

The service was a small property with 5 bedrooms, and the property did not have the space to provide separate bathrooms or women only spaces. Information given to clients prior to them attending rehabilitation did not explicitly state that the rehabilitation unit was mixed gender, although referrers were aware of this, this information was discussed during assessment and clients were offered a taster day prior to being admitted. Following our inspection the service told us they had updated information given to clients to explicitly state accommodation was mixed gender accommodation.

We scored the service as 3. The evidence showed a good standard. The service 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.

The rota showed staff numbers complied with or exceeded minimum establishment levels. The average turnover was 0%. Sickness absence was very low with 0% short term sickness and 2.54% long term sickness over the last 12 months. Managers had used 1 bank worker and no agency workers in the last 3 months. The bank worker had covered 5 shifts.

Managers had calculated the number staff required for the service. The provider had a safer staffing policy in place to provide guidance for identifying safer staffing numbers. The safer staffing numbers were 1 staff member overnight and at weekends and 1 staff member at the structured day programme. The service had a support worker, a caretaker who provided live in support and was available overnight, a counsellor, an admissions coordinator, a psychologist who worked 1 day a week at the service and the service manager who worked across 3 services. The staff teams for Acorn rehabilitation services in the area worked together to provide support and cover when staff were off or needed extra support and the manager could use bank staff if required.

When necessary, managers used bank staff to maintain safe staffing levels. When bank staff were used, those staff received a full induction and were familiar with the service.

The model for the service was primarily based on group therapy. However, some clients were not entirely clear about how much one to one time they would receive. Clients could ask for 1-1 sessions if they required them, but these were not regularly offered, and some clients had not had a 1-1 session.

Staff had received and were up to date with appropriate mandatory training. Training compliance was at 95%. The training was appropriate for the client group using the service and included learning disability and autism training; professional boundaries training and training specific to the role such as Naloxone training, trauma informed training and substance misuse awareness.

We scored the service as 2. The evidence showed some shortfalls. The service 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.

Most areas of the service areas were clean, had good furnishings and were well-maintained. However, the showers in both the main bathroom and the room which had an ensuite were mouldy, there was damage to the wall in the ensuite shower and the floor next to the shower was not secure, one of the bedrooms was not clean and the bath panelling was coming away from the bath and the sealant was broken and dirty. These presented an infection control risk and made these areas difficult to clean. The clients had a cleaning rota, and the service also employed cleaners to attend the property to carry out cleaning of the communal areas.

The service had personal protective equipment available for staff and had appropriate contracts in place for managing clinical and sanitary waste products.

Cleaning audits were carried out weekly as part of the building safety weekly checks, however these did not identify some of the concerns we identified during the inspection, such as the mouldy showers. Following our inspection, actions were taken to improve health and safety training for staff and to address the concerns regarding the mouldy showers.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, staff involved people in planning.

The service had a medicines policy in place, however this was not robust. The policy had a focus on clients self-administering and taking control of their own medicines. This had been broken down into different stages to enable staff to support clients to administer their medication where they had concerns that clients may struggle to administer their medication as prescribed. Where clients were on stage 1, their medication was kept in the office and staff observed clients administering their medication. Signed medicines records were not used during this stage, which meant there was no clear audit trail in the case of a discrepancy, whilst medicines were stored in the office. However, staff documented medication observation in case notes and this captured issues such as refusal of medicines.

The policy also mentioned controlled medication that required further documentation but there was no clarification on what the additional record keeping requirements were or how to put this in place should it be required.

Staff mostly followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal) and did it in line with national guidance. However, the providers policy stated that all medicines should be stored in a locked cabinet. We found the cabinet was too small to accommodate large bottles of medicines which meant 1 medicine bottle was not stored according to the policy.