Manifolds care Also known as Regus

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. This is the first assessment for this newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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. More work was needed to strengthen this area,

Staff recorded accidents and incidents; however, they did not consistently analyse these records to identify themes, trends or opportunities for learning. Staff told us they discussed incidents to support future learning. The registered manager told us they were exploring systems to capture and analyse this information more effectively.

The provider worked with people and other professionals to establish and maintain systems to monitor and manage safety. They aimed to ensure continuity of care, including when people moved between services.

Staff supported people to attend hospital admissions, routine appointments and access other services when needed. A relative told us, “[Family member] is taken to appointments; there is 2 particular carers that are good with this.”

The registered manager told us they communicated regularly with people’s community outreach case managers to coordinate care, including arranging health appointments and supporting transitions between services. Staff provided support during hospital visits, maintained continuity of care, and actively supported people during discharge by reviewing information and ensuring appropriate follow-up actions were completed.

The provider worked effectively with people or healthcare professionals to understand what being safe meant to each individual or how best to support them to achieve this. However, the provider did not always share concerns quickly and appropriately to all relevant agencies.

The provider reported safeguarding concerns to the relevant authorities and worked with them during investigations. However, the provider did not notify CQC promptly of the safeguarding concern raised, as required by law. The provider must submit notifications without delay and provide updates when additional information becomes available to enable CQC to monitor whether appropriate action has been taken. Following our intervention, the provider submitted this notification retrospectively.

Staff completed safeguarding training and demonstrated an understanding of the reporting processes they needed to follow. A staff member told us, “I would raise any concerns with the registered manager. I would report to CQC, if I was still concerned.”

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.

Although risk assessments in place were detailed with good guidance for staff. Monitoring and risk management practices were not always delivered in line with agreed guidance. Skin integrity and fluid recording did not consistently reflect the guidance set out in care plans. However, daily notes confirmed regular skin integrity checks were carried out by staff.

Relatives we spoke with did not express and concerns about the safety of their family members and told us people were safe with staff. A relative told us, “They are aware of risks, I will pull them up if concerned. I say what needs to be said.”

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

The provider carried out an environmental risk assessment before individuals began using the service. Staff had completed health and safety training and understood what to look out for to ensure the environment was safe.

The provider ensured there were sufficient staff with the appropriate qualifications, skills and experience to meet people’s needs. However, further improvements were required to strengthen recruitment practices and ensure consistent staff support.

The provider did not operate robust recruitment processes. Where DBS checks identified concerns, the provider did not complete appropriate risk assessments or document how they would manage identified risks to ensure people’s safety. The registered manager told us the concern was historical and explained they had introduced additional monitoring arrangements; however, they had not consistently recorded these. Following the inspection, the registered manager sent us a risk assessment and an enhanced supervision plan.

Most staff reported completing training appropriate to their roles; however, the provider did not make competency assessments for medicines administration and PEG (Percutaneous Endoscopic Gastrostomy) care available during the inspection. The provider submitted these following the inspection, with recorded completion dates after the site visit and signatures from the registered manager. Despite these gaps, relatives told us they were satisfied with the care provided, including support with medicines and PEG care. The registered manager explained training was delivered face to face and the trainer assessed staff competency during training sessions.

The provider planned staffing levels in line with people’s care packages, which supported the safe and consistent delivery of care. A relative told us, “They always turn up and at the right time.”

Staff told us they felt supported by the registered manager and said they received regular supervision. One staff member said, “Yes, I have received supervision. This is carried out regularly and provides an opportunity to discuss my performance, training needs, any challenges within my role, safeguarding, service user outcomes, professional development and general wellbeing. It is also an opportunity to raise concerns and receive feedback and support from management.” However, records of supervision did not consistently evidence this level of support. The registered manager created an overview system to ensure staff supervision and support are recorded more consistently.

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.

The provider had infection prevention and control (IPC) policies and procedures in place to guide staff. People told us staff wore appropriate personal protective equipment (PPE) when providing care.

The provider ensured medicines and treatments were managed safely or in line with people’s needs, capacity and preferences.

Staff received appropriate training in medicines administration. However, the registered manager completed most competency assessments after the inspection. Staff supported 1 person who required emergency rescue medication, and care plans included clear guidance outlining when staff should administer this.

However, the registered manager carried out competency assessments without completing additional training to support this role. Following the inspection, the registered manager provided evidence they had registered for an additional qualification to strengthen their competence in assessing staff practice.