Drumconner Lancing

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding and staffing.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always identify, investigateor report safety events. Lessons were not learnt to continually identify and embed good practice.

Incidents which resulted in injuries to people were not reviewed or investigated by the management team to mitigate reoccurrence and allow for lessons to be learned. We reviewed multiple incident records where trends and patterns had not been identified; these included injuries during personal care, continence support and moving and positioning. The management team had not identified these trends or investigated the root causes to see what could be done differently.

Following our feedback, the provider sent us evidence of changes to the reporting system to allow better oversight of incidents so they could be responded to appropriately. We were unable to assess the effectiveness and sustainability of these changes at this assessment.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. Pre-admission assessments did not always fully consider people’s needs and ensure they were matched with the skills and knowledge of the staff team.

We asked the registered manager for evidence of staff training during our assessment and staff had not always received training or guidance for specific conditions, and this increased the risk of people not always receiving safe care and treatment. Information was not always available to ensure people’s needs were understood and met as soon as they were admitted to the service.

Systems in operation did not always identify the need to seek external advice and guidance without delay. This meant staff could not be assured people were supported in a consistent and predictable manner or their needs were always met in line with current good practice guidance.

Whilst our assessment found shortfalls with safe systems of care and the level of guidance available to staff, healthcare partners spoke positively about the level of engagement and communication with the team.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

Staff were able to describe what constituted abuse, however, had not always considered some incidents as potentially reportable within safeguarding. Incidents of unexplained injuries to people or injuries which were sustained following support from staff, had not been reported to the local authority safeguarding hub. One person’s care record identified a number of instances where staff used unauthorised restrictive practices whilst providing personal care, however this had not been reported to the safeguarding hub. We raised a safeguarding and discussed this with the registered manager who took action to ensure staff had clear guidance including consideration of least restrictive options. During our assessment, we raised safeguarding concerns for a further 5 people in relation to injuries sustained during personal care.

Staff and management did not always work within the principles of the Mental Capacity Act 2005 (MCA). The MCA sets out how to assess and make decisions on behalf of people who lack capacity. Decisions made by nurses and staff did not always include consultation with people involved in the persons care, or the persons wishes. However, the registered manager had oversight to ensure Deprivation of Liberty Safeguards (DoLS) authorisations were in date and that imposed conditions were known and being met. Relatives told us the registered manager and staff kept them up to date when they had reported concerns. One relative told us, “My loved one had a bruise on their arm. I raised it and they completed an internal investigation.” The registered manager told CQC this incident had been reported to the local authority safeguarding hub.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks of falls were not effectively assessed and managed. People were identified as being at risk of falls but there were not adequate measures in place to mitigate risks to ensure their safety. One person had a history of falls, lived with a cognitive impairment and was assessed to be at high risk. Risk assessments lacked personalised information and did not include any consideration of the risk of falls associated with the staircase. The registered manager and staff told us that staff were mitigating risks of falls on the stairs by encouraging people to call for staff to support them to use the lift. However, we checked, and this person was not able to consistently call staff for support, we were not assured this measure adequately managed risks for this person. We raised our concerns with the provider and registered manager who gave assurance of actions they were now taking as a matter of urgency. This included introducing a seat sensor to alert staff when the person was moving from their chair and changes to the environment to mitigate risks to people associated with staircases.

The provider failed to operate effective incident management systems We reviewed incident records and identified a number of people had acquired injuries whilst being supported to move and position. The registered manager had not identified this trend and as a result was unable to demonstrate actions they had taken to mitigate and manage risks. Care plans were generic for people who lived with specific health risks and for those where equipment was needed to support them. A staff member told us, “We are always thinking how we can improve, we have to be very careful during personal care and are always chatting with each other in how to change routines.”

The registered manager and staff ensured risks associated with changes in a person’s health were managed appropriately. A visiting health professional told us, “Nursing staff are very responsive to queries and any changes made by the GP on ward rounds. They communicate well with the surgery regarding any issues with their residents, they are always prepared for the ward round and if any issues arrive between the weekly visits they raise.” Some people were receiving a modified diet. Staff who prepared the food were able to access guidance on what level of modification was required. We observed people being supporting in line with their assessments as detailed within Speech and Language Therapy (SaLT) guidelines.

The provider did not always detect and control potential risks in the care environment. The providers safety checks had not identified risks to people from unrestricted staircases. The risk assessment in place for use of the stairs was generic and control measures lacked detail and were ineffective. There were no restrictions in place to prevent people who were at risk of falls from accessing the stairs independently. Following our feedback the provider took prompt action to address concerns including reviewing the use of one staircase for people due to issues with lighting and its width for people. They also provided evidence of actions they took to reduce and mitigate risks to people on all other staircases in the service.

The provider failed to act in a timely manner when risks had been identified. For example, A Fire Risk Assessment (FRA) dated 29 May 2024 included reference to a number of fire doors which could not be confirmed as meeting current compliance requirements. The FRA had set a 6-month completion date for remedial works. This had not been completed at the time of our inspection. The provider was in the process of prioritising this work following it being identified during a CQC assessment of an application to increase the capacity within the home. We were assured this work was completed during the course of our inspection.

People had up to date personal emergency evacuation plans (PEEPS) to guide emergency personnel on how much support people would require to evacuate the building. Checks on electrical equipment and water safety had been conducted. However, we identified the window restrictors were not fully effective and could be unlatched easily. We fed this back to the registered manager who said they would address the concern immediately.

The provider did not make sure there were enough qualified, skilled and experienced staff. People consistently spoke of delays in staff responding to their calls for support. Comments included, “There were not enough staff and sometimes I have to wait for up to an hour, mornings are the worst.” And “They need to employ more staff, the wait, when I ring the bell can be up to 30 minutes.” A relative told us, “I don’t think there are enough staff especially at weekends. [Name of loved one] will call for help. I hear bells being rung and being left unanswered for a long time.”

Records and our observations confirmed excessive call wait times. The registered manager failed to operate effective systems to monitor staffing levels and analyse response times. Call bell audits had not included consideration of people’s dependency and support needs in relation to staffing requirements. A Staff member told us, “In the morning sometimes you have to support 9 or 10 people, we let them know we're on our way. I'd like to get to call bells quicker, but we'd need more staff to do that. I think the staff level should depend on the dependency of people. You could have three people that take a lot more time to support than 10 people with less needs.” The failure to monitor staff deployment increased the risks of people not receiving support with their needs in a timely way. We raised our concerns to the registered manager who informed us they were in the process of implementing a new reporting tool to provide further detail to inform their staffing assessments. We were unable to assess the effectiveness and sustainability of these changes at this assessment.

The provider did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. A number of people lived with advanced dementia, some staff told CQC they had not had training in respect of supporting people with dementia who may display emotions of distress. For one person, records relating to care evidenced support being provided by staff who lacked knowledge and skills. Care plans referenced staff working with a “positive behavioural approach”. Very few staff had received training in positive behaviour, and we saw no reference in training records to dementia training. Care records identified shortfalls in staff skills which included references to care being provided in peoples’ best interests. Best interest decisions had been made without capacity assessments being fully completed within the principles of The Mental Capacity Act 2005 (MCA). This highlighted a lack of understanding of mental capacity and increased the risk of people not receiving support which was appropriate or the least restrictive. Training records provided during assessment showed the majority of staff had not completed MCA training.

Not all staff received training in relation to supporting people with a learning disability and autistic people which required providers to ensure staff complete training in learning disability and autism to all staff, including ancillary staff, at a level appropriate to their role. The registered manager told us they were in the process of arranging dementia training with a specialist training provider and were reviewing their staff training processes.

Whilst our inspection identified significant gaps in staff training and skills, people and their relatives spoke positively about the knowledge of staff. Comments included, “The staff are very well educated in their respected knowledge of skills and support to my relative at all times.” And “[Name of Loved one] is confident in staff, the nurses know their jobs.”

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 they were satisfied with the standards of cleanliness at the service. One relative said, “It is beautifully clean.” We saw staff using appropriate Personal Protective Equipment throughout the inspection. Housekeeping staff were observed cleaning throughout the day. Audits were conducted consistently to ensure standards of infection prevention and control were maintained.

The provider generally made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Systems for recording administration of medicines were not always robust. We noted that Medicine Administration Record (MAR) charts were not always completed in relation to topical medicines. Topical medicines are applied directly to the skin. A manager told us that care staff recorded administering topical medicines within care records. There was no consistent record of administration, and this meant the provider could not be sure whether the person had received their medicine as prescribed. Medicines were administered by registered nurses and senior staff who had completed training and had their competencies regularly assessed. People who required time specific medicines received them in accordance with their prescription.

Relatives told us they were informed and included in changes to their family member’s medicines. A relative told us how staff supported them to review medicines, “I have had phone calls asking me to come in to discuss (medicines), it was discussed and they are only on really necessary ones now.” The registered manager gave an example where staff had noticed adverse medicine side effects for a person, following a review the person was more alert. Medicine errors and near misses had been documented and responded to appropriately.