suite B, 1st Floor Shaw House 2-3 Tunsgate Guildford Surrey GU1 3QT Also known as Office

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 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 legal regulation in relation to safe care and treatment, safeguarding, safe and effective staffing and fit and proper persons employed.

This service scored 53 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.
The provider failed to evidence they had a robust system and process in place to complete route cause analysis of incidents, and to holistically view all incidents and accidents for learning. This meant learning outcomes were not always established and evidenced as being shared with all staff. The provider failed to maintain a robust system of recording complaints, and as a result of changing systems, this meant previously received complaints were inaccessible . This also meant the provider was not able to evidence how they reviewed issues raised and any learning taken from it to reduce risk of recurrence.
The provider told us they used daily huddles and supervisions with staff to discuss training, learning and wellbeing.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.
Staff noted concerns about people’s health, care and wellbeing in their care records. However, staff often reported concerns to the office before seeking any medical attention for people. This meant people’s treatment was not always provided without delay which could affect their health and wellbeing. We found some people discharged from hospitals were received with unexplained bruising and scratches. The provider did not demonstrate how they worked with people and healthcare partners to investigate these concerns, and to mitigate the risk of people experiencing potential harm and abuse.We shared these concerns with the provider, and they confirmed they would now liaise with hospital discharge teams where appropriate when a person returns with marks or bruising, and the learning has been shared with staff.
We found at times staff were making clinical decisions without seeking guidance from a healthcare professional. For example, in people’s notes we found entries such as, “[Person] complained of the pain in [their] left side torso. I examined the skin for bruising and there weren’t any. I applied slight pressure, and [person] said it was painful when I applied the pressure. I called the office to report and discuss this, and we agree that we could buy some Voltarol.” This demonstrated the provider was not working well with healthcare partners to maintain safe systems of care for people, and to ensure people received timely diagnoses and appropriate medical support . This meant people were at risk of receiving unsafe care and treatment.

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.
The registered manager confirmed they had not raised any safeguarding referrals since the service registered. The registered manager also confirmed there was no safeguarding tracker in place because of no referrals raised. However, we found examples of safeguarding incidents which required a referral to appropriate agencies. For example, one person sustained a bruise whilst being hoisted and another person was found with numerous bruises and scratches. These incidents were not safeguarded and the provider failed to demonstrate a robust system was in place to identify, investigate and monitor safeguarding concerns. This also failed to demonstrate staff were able to raise concerns directly with safeguarding agencies without delay. This meant people were at risk of harm or abuse due to lack of action by the provider.
 

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.
Staff did not always ensure they contacted healthcare professionals when people required clinical advice and guidance. For example, we found following some incidents, staff applied treatment which was not in line with best practice guidance. This meant people were placed at risk of deterioration in their skin integrity.
A second person had developed a skin integrity issue that needed input from a healthcare professional. However, we found staff applied treatment without consultation from a healthcare professional. This put the person at risk of further injury and deterioration of their skin integrity.
We found the provider had established care plans and risk assessments for specific conditions such as diabetes and oxygen therapy which were person centred.
 

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 completed risk assessments of the environment, and in accordance with people’s individual needs to maintain their safety in their own home.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff.
The registered manager told us, “We want confident staff who deliver care, they need to be properly trained. We have 87 training modules which are required to be completed before passing probation.” However, we found staff were supporting people with moving and handling, and catheter care. However, they were not fully trained to carry out such tasks. Or staff had not had their competencies checked to ensure they were competent to complete such tasks. Although staff had completed training in these areas, the application of their knowledge and skills had not been assessed to ensure people received support from skilled and experienced staff.
Furthermore, staff assessing competencies were not trained appropriately to carry out staff assessments. The registered manager did not ensure there was a safe and effective process in place to complete required training for staff. This meant people were put at risk of being supported by untrained and unskilled staff.
The registered manager did not operate effective and robust recruitment and selection procedures to ensure they employed suitable staff. We found discrepancies with gathering information of full employment history and unexplained gaps, evidence from previous employments related to health and social care regarding staff conduct and verifying the reasons for leaving.
We shared these findings with the provider during our assessment. They provided us with updates how they would be addressing these concerns.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.
Staff told us they were supported with how to manage the risk of infection. One staff said, “We have access to lots of PPE, as much as we need. We dispose of what we use by wrapping it up and placing into yellow bin. If they don’t have a yellow bin, we dispose of it in an outside bin. We are told in the care plan where those bins are.”
Relatives also felt the provider managed the risk of infection well. One person told us, “Staff wear uniform and use PPE as necessary.”
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
‘As needed’ (PRN) medicine protocols were not always person centred and detailed to ensure these medicines could be administered safely and in line with people’s individual needs. For example, one person with a GTN spray had a protocol in place which lacked sufficient detail. GTN spray, or Glycerol Trinitrate, is a medication that belongs to a group of medicines called nitrates. It works by widening blood vessels, which increases blood flow to the heart, and is primarily used to relieve chest pain (angina) at the onset of an attack. The person’s PRN protocol stated to liase with the GP if there was no desired outcome from administering this medicine. However, the desired outcome and a description of these symptoms were not captured by staff.
For another person we found their PRN protocol did not detail the dose, minimal interval and maximum dose per period. This meant there was a risk this person would not have their medicine administered safely and in accordance with prescriber’s instructions.
Some medicines were listed as variable doses. However, there was no clear guidance to inform staff when to administer different doses as staff were not clinically trained to make such decision. This meant there was a risk people may receive inaccurate and inconsistent doses of medicine.
We found some people were prescribed inhalers, however the competency forms completed by staff did not evidence all staff were competency assessed for administering this type of medicine.

We provided feedback to the provider and after the assessment they informed us they had completed a review of medicine administration records (MAR) and now implemented changes to ensure PRN protocols were more detailed.