Salis Care C.I.C.

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 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 how risks to people’s safety were managed and the management oversight of staff training.

This service scored 56 (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. There was a lack of consistency in how staff reported incidents and safety events and systems to review and investigate concerns were not robust. Lessons were not always learnt to continually identify and embed good practice. Records showed that some incidents of people demonstrating distressed behaviour were reported within daily records but were not recorded on incident forms. Where incident records had been completed these were not reviewed by the management team to ensure all relevant action to reduce immediate risk had been taken. There was no analysis of incidents completed to identify trends or themes and minimise the risk of concerns happening again.

Staff told us they felt listened to when discussing incidents with the management team and were able to give examples of where changes to people’s care had been made to reduce their anxiety. However, there was also a culture of accepting incidents happening as a result of people’s anxiety rather than fully reviewing their care to reduce this risk. The manager told us due to the size of the service they felt able to manage incidents through discussions with staff but acknowledged a more effective system was required.

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 to ensure there was a consistent approach to people’s care. The provider had begun to implement systems to ensure safe systems, pathways and transitions between services. However, time was needed to ensure these systems were embedded into practice.

Relatives told us that prior to the new management team being in place some health appointments for people were missed. The relative told us as a consequence, they felt they needed to attend appointments with their relative or reminded staff of appointments. The manager and director of Salis Care told us they were aware of concerns regarding communication between different services involved in people’s care prior to there being changes in the management team. This had led to difficult relationships with some professionals and lost opportunities to review people’s care. The new management team had begun to work more effectively with professionals and were regularly meeting with health and social care partners. This had led to more positive outcomes for people and less restrictive practices being used.

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

The provider had not always ensured people were protected from the risk of financial abuse as the systems in place did not ensure accountability of regular audits. The manager told us that as a result of these concerns, new systems had been implemented. Records showed these procedures had been risk assessed for each person, new processes for recording implemented and regular finance checks completed. The manager and director were confident the system was working well, and we saw records were more robust. Whilst staff told us they felt confident in using the new system this will take time and continued monitoring to ensure it is fully embedded into practice and effective in keeping people safe.

People appeared relaxed in the company of staff and relatives told us their loved ones were safe from the risk of abuse. One relative told us, “Staff are warm and welcoming, and you can see they have a good relationship with [relative]. I have no concerns they would hurt [relative] in any way.” The new management team had implemented systems to ensure any safeguarding concerns were appropriately reported. Staff were aware of their responsibilities to report and record concerns.

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. Some relatives told us opportunities for their relatives to go out had reduced due to the lack of planning regarding how risks would be managed. The manager told us they were aware there needed to be a greater emphasis on positive risk taking. They told us this process had started within the home and information was being gathered to develop this further when people went out.

The provider had failed to ensure staff had up to date guidance on the support people needed to manage risks to their safety and well-being. We found risk management plans did not reflect the support people were receiving and had not been updated for long periods. The manager and staff were able to describe changes which had been made to people’s support. Whilst in many areas the changes made had been positive, the failure to have effective systems to plan for these changes had on occasions led to an increase in people’s anxiety and distressed behaviour. Changes had been made in areas such as how people were supported to eat safely, reducing restrictions in place such as locked cupboards, and the support people received when anxious. Despite these significant changes, people’s care records had not been updated to provide guidance to staff. Whilst people were supported by staff who knew them well, the lack of a clear risk management process and written guidance meant there was a risk people would not receive consistent support.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Staff supported people to live in a safe environment and to manage their tenancies. Reporting systems were in place to ensure maintenance concerns were reported promptly and action taken. Staff had received fire training and were aware of the actions to take in the event of such an emergency.

The provider did not always make sure staff had the skills and experience required to support people. They did not always make sure staff received effective support, supervision and development. We received mixed responses from relatives regarding staffing at the service. One relative told us, “They need more training about autism, more understanding about how to do things. They are willing and pleasant but not all of them have the skills.” Another relative told us, “The staff are really good and know how to care.”

The provider did not have robust systems to monitor staff training and supervision. The manager told us the training matrix was not up to date and no supervision matrix had been completed before January of 2025. This meant the provider did not have an effective process to monitor staff skills and performance. We reviewed an updated training matrix forwarded by the provider following our site visit. This showed staff had completed training in supporting people with a learning disability, Attention-Deficit/Hyperactivity Disorder (ADHD) and autistic people. However, staff told us these were short remote eLearning courses. This was confirmed by records which showed staff had completed numerous courses on the same day. This meant the provider had not ensured staff had received in-depth training in line with the needs of the people they were supporting. The manager and director told us they were working on priority areas such as ensuring staff had the required training to keep themselves and others safe when people were experiencing anxiety and distressed behaviour. Records confirmed this face-to-face training had been completed by the majority of staff. The manager told us the induction of staff into the service had also been updated to ensure this was more comprehensive. There was positive feedback regarding this process as staff felt they had more time to get to know people and understand their needs.

People were supported by sufficient staff in line with their assessed needs. We observed there were the correct number of staff available to support people. Staff told us they never worked with less than the required staffing numbers and staff rotas confirmed this was the case.

Staff were recruited safely. Recruitment procedures included completing checks on staff work histories, obtaining references and Disclosure and Barring Service (DBS) checks and conducting interviews. DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people at the time.

The provider assessed and managed the risk of infection. People were supported to keep their home clean and had access to the materials needed to maintain this. One staff member told us, “We do a lot of the cleaning but we try to encourage [people] to help and be involved.” Staff had access to personal protective equipment (PPE) to use when supporting people with their personal care.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Where people were prescribed as and when required medicines (PRN) prescribed for their anxiety, records showed these were not regularly used. However, we found protocols for the use of PRN medicines lacked detail. They did not always make clear what steps should be taken prior to administration to minimise it being used. Where records showed PRN medicines had been administered, the time was not always recorded. This meant there was a risk the correct gap between doses may not be left. The manager gave assurances these concerns would be addressed with staff immediately and protocols updated.

Staff had completed training in medicines administration and their competency had been assessed. Records showed that people were supported to have their regular medicines in line with their prescriptions. Medicines were stored individually, and people were supported in a safe and respectful way.