Stepping Stones Red Marley

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 69 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place to monitor and have oversight of incidents and accidents. Accident and incident logs were completed by the registered manager to identify and understand why a person had become distressed or why an incident occurred and what could be changed to prevent further occurrences. The registered manager told us, “All incidents are recorded on reports to build a picture of why and what was happening, how it occurred, are we having right training and how often. It’s not often but has happened.”

There was a positive approach to learning from events in the service. We saw following incidents staff received a debrief to reflect and express their feelings about the event. The registered manager told us, “We look at each incident and what is needed and how everyone feels, some are straightforward and just happen, others we need to look at further and go away and really think about.” Staff told us they received training around managing and recording incidents and were confident of this process.

Appropriate actions were taken following medicine errors. For example, staff were supported to undertake further training, discuss in supervisions and complete self-reflection. The registered manager said, “We want staff to come to us and tell me what has happened, we can work with that.”

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.

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity. We saw that referral information was recorded in people’s care plans about how transitions should be managed and the importance of maintaining the right package of care around the person.

People were positive about their transition into the service and support when they accessed other healthcare settings. One person told us it had been, “well managed” by the service, and “they were very good.” One health and social care professional said, “The service and staff, in my opinion go above and beyond during transitions. With [service user] staff made every effort to build rapport by visiting him in hospital months before he moved there. The service user was involved in the decoration of his room and visits were facilitated with ease and in a welcoming manner. Staff attended handover meetings and gave updates on progress throughout the transitional period.”

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.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. This included discussing safeguarding in staff meetings and supervisions, staff training, recording and investigating incidents and working with the appropriate safeguarding authorities to keep people safe. The registered manager told us that at times of incidents depending on what was needed, the nurses would be given the opportunity to lead an investigation so that different people had insight and enabled impartiality at those times.

Staff and leaders were aware of the warning signs that may suggest a closed culture was developing and took action to address them. The registered manager told us, “When I first came there were staff cliques, and I had to do a lot of work and some staff left. Now and again, I need to remind staff if I see things that indicate we are not all one team. I am realistic as we ask a lot of the staff, but I see a bigger picture of what is happening around home.”

The registered manager and staff were aware the people in the service were more vulnerable to abuse and neglect due to their health and support needs. We spoke with the manager about how they helped people understand sexual safety and they gave us an example of one person they had supported to ensure they had information available, understood any potential risks and the importance of understanding and being able to give consent. External professionals were also involved to provide extra or specific support to this person. The registered manager told us “..It’s managing risk and giving reassurance and allowing people to take risk, people can’t learn if they don’t take risk. We work as teams and go through the process with the people we support.”

Staff demonstrated confidence in their role to recognise and raise any potential safeguarding concerns. Staff told us, “Had training, first port of call go to [registered manager’s name], her door is always open and if she didn’t do anything I would go higher up, but she makes me comfortable” and “I would report it and raise it. I feel confident. Be transparent and open and honest, I work across all houses and both teams. Never seen anything I’m not happy with.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks had been identified, recorded and as far as possible mitigated for people. We saw good clear recording of how to support people around risks that were specific to the individual. This included areas of smoking, behaviour, financial, community support and mental health. This was balanced with enabling people to take positive risks and make decisions as they chose. People living in the home were all mobile and for this reason call bells were not in situ in bedrooms. People were assessed individually around the support needed to call staff if required. Some people had regular agreed checks when in their bedrooms which were documented, for other people a sound monitor was outside their bedrooms with their agreement, and one person had an audio device in their room due to their health condition in case of an emergency.

Staff understood there were times when people became distressed and took steps to understand why a person was distressed and what support they needed to express their emotions. Staff spoke to and about people at times of distress in a respectful way. At times these situations escalated to physically aggressive displays of behaviour. Staff had received training in managing these incidents and were confident in supporting people at these times. One staff told us, “I feel confident dealing with that, it’s a stressful time for all but my goal is to support the person and keep them free from harm. Got a good support network here, can talk to people, [registered manager] when she has time, [they] are really good and helped me a lot and my team lead. I have had training and know there is more training which I’m excited for.”

Restraint was only ever used as a last resort. If staff used restraint, it was lawful, for a legitimate purpose, safe and necessary, and staff followed best practice. Following any incidents staff took part in a debrief to reflect, process and consider if actions taken were appropriate and achieved a good outcome for the person involved. Staff told us, “Had training and around low arousal and when people settle and they calm. We have walkie talkies and can call for help if needed, we have debriefs” and “Never had to use restraint on anyone. It’s not a good thing. I use my voice to turn a situation around; I have stepped in the way of things being thrown.”

Relatives felt that staff had good knowledge of people to alleviate and minimise incidents of distress commenting, “..Several of the staff have come to understand her wishes, concerns and behaviour and to respond to early signs of distress” and “From all I've seen (and read in reports), considerable effort goes into managing risk. There are indeed restrictions, inside the house and outside, but I don't feel they are at all inappropriate.” One health and social care professional told us, “The care plan I saw was very person centred, they understood some of the differences, in terms of behaviour. They understood the difference between unusual behaviour and wishes (and accommodated that) and unacceptable behaviours (which had a behavioural plan attached).”

We saw that people had personal evacuation plans in place to show the support they needed to leave the building in an emergency. These were personalised as to how the individual would process an emergency and if they had any health-related concerns that would impact on them evacuating. Two people living in the home told us if they heard the fire alarm they knew to go straight out into the garden to keep safe.

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

Facilities, utilities and technology were well-maintained and monitored to support staff to deliver safe and effective care. The registered manager had robust systems and processes in place to ensure daily and monthly checks and audits were completed across areas including medicines, water checks, security, electrical testing and health and safety. Any outcomes that were needed were recorded on an action plan and reviewed regularly to ensure they were completed in a timely manner.

The buildings were in need of some upkeep and redecoration. This was evident in some of the bathrooms and communal spaces. The registered manager was open about this, and the new provider had planned a visit to assess the work needing to be completed. A recent fire safety inspection had identified some areas for improvement including moving some of the displayed artwork as it could increase the risk to people in the event of a fire. The registered manager had already started work addressing these recommendations prior to our inspection visit and recorded these on their action plan.

The environment afforded people to spend time with others and in more quieter areas should they wish to be away from other people. There were activity rooms including a games room, art room, a talking therapy room, quiet lounges, and extensive grounds for people to spend time. People’s relatives mostly felt that the environment was well suited to meet their family member’s needs. Relatives said, “Definitely. Can go to the garden and shops. Has a little job, watching cars in the car park”, “Can go out every day if she wants to” and “Yes, routine, quiet and calm, which are very important to [person name], seem to be well maintained. Her general health and physical needs are well cared for too.” We observed that people were able to personalise their bedrooms as they chose and where required equipment to support people was in place.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Whilst there were sufficient numbers of staff to provide safe levels of care the staffing levels did at times impact on flexibility around activities and time spent with people. People and relatives gave mixed feedback about staffing levels. One person said, “I think there are enough” and another said, “No I don’t think so. It’s probably down to money.”

The registered manager was open in saying recruitment had been a struggle and this had caused the deputy manager to be absorbed into staffing numbers on the floor which then impacted them being able to undertake their recruited role. The registered manager commented, “We have bank staff but with nature of our guys they need consistency, so agency doesn’t work for us, and it’s hard, it means we have to re-prioritise what we do and who is doing what and with annual leave it impacts.” We saw a staffing contingency plan was in place to address shortfalls which included regular staff picking up extra hours, informing people of changes and other staff roles who were appropriately trained, stepping into care roles.

Staff felt there was an impact from staffing levels for people saying, “Depends on the day, enough to be safe but beneficial to have more, to go out more and for people to go out” and “Currently there is not enough, it’s a struggle and its noticeable, for the people, impact in behaviours I’m seeing, changing faces and people not being here anymore and causing confusion, they can’t process it and it’s in the behaviours. Staff here [this house] are a constant. I think its safe levels.”

Safe recruitment practices were carried out. People were supported by staff who had undergone robust employment, and criminal checks. Following recruitment staff undertook training and shadowing of more experienced staff. The registered manager said, “Staff shadow and do training and buddying up with someone and also having experience across the houses. We can see where skill set is and where they are best placed.” One staff said, “We had a job description and info needed and were pushed in the right direction with policies and procedures.”

Staff received the support they needed to deliver safe care. This included supervision, appraisal and support to develop, improve services and where needed, professional revalidation. We saw that staff attended meetings dependent on their role to receive updates, share information and reflect on positive practice. One staff member said, “We have team meetings, we get together as much as we can, meetings with nurses and manager sits in.”

The registered manager told us they made sure they were also available to staff outside of formal meetings and supervision commenting, “Walk arounds, I record this and do it at different times, sometimes several times a day depending on what is needed, check in with everyone and for staff and service users, see what’s going on, those who want me will come and speak to me. Have an open-door policy, people will come and pop in.” One staff told us, “I have supervisions with team nurse and have regular staff meetings. I can say anything if I need, I will say anything, so it doesn’t fester.”

Staff received training appropriate and relevant to their role. Staff spoke positively about their training and how it equipped them effectively to carry out their roles. Staff told us, “I have done learning disability and autism awareness training, we do this online, have had face to face training as well for fire” and “Had full training from fire to positive behaviour management, really good.”

The registered manager kept a training matrix to ensure staff kept up to date with their training relevant to their role. We saw that staff had completed training in mental health, learning disability and autism awareness to meet the specific needs of people they supported. The registered manager told us, “..Staff do training, and we also teach them by experience, training gives awareness but need practice and navigating. We have different styles of nursing employed, mental health, learning disability and adult nursing. With [person name] we did dialysis training, we weren’t experienced and sourced this. The NHS teams were good and set up individual training..”

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 were protected as much as possible from the risk of infection because the premises and equipment was kept clean. One relative told us, “Oh yes, the kitchen is spotless.” The service had received a food hygiene rating of 5 from the Food Standards Agency this year.

Although the service was kept clean there were areas including bathrooms, hallways and communal areas that needed some redecoration and updating. The registered manager was aware of this and had an action plan in place to address these areas. One relative commented, “Yes (clean), but in such a way that it is not homely. Although there is artwork, there is no softness, very cold.”

Staff had completed training in infection prevention control and there were cleaning schedules completed during the day and night shifts. People were encouraged to take responsibility for cleaning their bedrooms but were supported by staff where needed.

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.

Although the management of medicines was mostly safely managed, there were some areas of improvement needed. During our inspection we observed that one person’s medicine which required increased security had been left out in the office. The nurse on duty and deputy manager were unaware it had not been put away when this person returned to the home. The registered manager took the appropriate action in addressing this error and increasing awareness with staff.

Each house had a secure medicines area within the care office. However, this had the potential to cause disruption to the nurses when they were managing medicines as other staff would come in and out. We saw that the temperature of the room medicines were being kept in was not recorded due to the frequent footfall within the room. The registered manager said they were considering how medicines could be kept going forward and if a separate room could be identified.

All other practice observed was safe. Medicines were administered to people appropriately and accurate records of medicines were kept. There was information recorded for staff about people’s medicines and any possible side effects they needed to be aware of. Where people required their medicines to be given covertly (without their awareness) this was undertaken safely, recorded clearly and with the agreement and involvement of the person’s GP, relatives and other consultants.

The nursing staff understood the principles of STOMP (Stopping Over medication of People with a learning disability, autism or both) and worked with other health professionals to stop over medication and ensured people received medicine reviews. Staff supported people where they were able to self-administer their medicines and gave an example of one person who was helped to manage their own blood sugars and insulin doses. People told us they received their medicines and staff supported them safely. One relative said, “Staff support is very good.”