Archived: The Chase

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 Inadequate. At this assessment the rating has remained 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 safe care and treatment, safeguarding, the safety of the environment and safe staffing.

This service scored 25 (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. Staff did not 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.

Although there were systems in place to review and analyse incidents, these were not always effective at improving people’s quality of care and monitoring was not robust. A person had recently fallen and their care plan had not been updated to describe the care they needed to receive to prevent them from falling again. Instances of abuse or neglect such as physical abuse directed by people towards their peers had not always been identified or reported appropriately to bodies such as the local authority or CQC. Instances of distress were not being appropriately analysed or learned from, with incidents identified during the inspection that leaders were not aware of.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Although we saw example of positive monitoring of risks to people and engagement with healthcare partners, this was not consistent and placed people at greater risk of harm including when transitioning between services.

During our inspection 1 person had been supported to visit overnight, however the provider had not appropriately risk assessed the person leaving the service with their medications. This person had been assessed as lacking capacity to manage their medications safely, however staff handed them their medications rather than to a person assessed as capable to do so. As a result, this person had not taken their medications including time sensitive Parkinson's medication which placed them at greater risk of harm. Another person had experienced significant trauma from a hospital admission, but there was no guidance on how to safely support this person should they need to be re-admitted.

However, professionals we spoke to gave positive examples of the service responding to advice given to support people safely. One stakeholder told us “It’s easier for them to find information now. I can see lots of communication with health services, you can see things are being referred promptly. They will give it their best shot and communicate with us”.

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.

There was inconsistent knowledge amongst the staff team about their responsibilities to safeguard people from harm which remained a concern from the last inspection. Staff weren’t always aware of their responsibilities to raise a safeguarding referral or how to do so. One staff member told us “I’m not sure how I would do this” and another stated “The most important thing is to contact CQC” which risked delaying people being protected from harm.

Where incidents of abuse or neglect had taken place, these had not always been referred by the provider as a safeguarding or a notification made to CQC. We saw one person had recently hit and attempted to hit other people on several occasions, but these had not been appropriately reported. Systems in place at the service did not consistently safeguard people from harm, for example ensuring they could always receive the medications they required or that risks to people were fully assessed to ensure their safety.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where the risks to people were deemed sufficient that restrictions such as living in locked accommodation were needed, to ensure their safety, appropriate authorisations were sought and recorded.

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 to people were not always identified, understood or documented to allow staff to provide care that consistently ensured people’s safety. This included risks posed by the home environment, around medications, infection prevention and by complex health conditions. Where incidents had happened, people’s care plans had not always been updated as a result with appropriate guidance of how to prevent this event from reoccurring. Some information in people’s care plans was generic, for example one person had a risk of seizures and there was very little information about how these would present or what staff should do as a result. The information was generic around epilepsy specifically rather than this person’s specific needs. Staff knowledge in this area was not consistent and we could not be assured that they would receive the support they needed if they were to have a seizure. There were large gaps between fluids and food being offered, and we could not be assured that the risk of malnutrition or dehydration was being appropriately managed.

The monitoring of some clinical risks such as constipation, diabetes and wound care had improved and was now being managed safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

There were hazards in the environment which placed people at greater risk of harm, which had either not been identified by the provider or appropriate action had not been taken to remedy them. Despite the majority of service users being at risk of falls, the flooring was damaged and poorly repaired which presented a trip risk. Some risks around fire safety had not been managed appropriately, and actions such as external surveys of external escape routes and compartmentation had not been undertaken despite being recommended in their fire risk assessment. During our inspection the rear garden was heavily overgrown and the provider told us was unsafe for use. Yet they had not taken action to address this.

However checks on utilities such as gas and electricity, and on equipment being used were being undertaken. There were regular fire drills and checks on evacuation routes, and that alarms and emergency lighting were functional.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Although people and staff we spoke to did not have concerns about the levels of staffing, we found these were not leading to delivery of safe, responsive or person centred care. For example people were regularly recorded as going as much as 5 hours after waking up before they were offered anything to drink or eat, and did not having access to meaningful engagement or activity.

There were people on the 1st floor that were cared for in bed. Staff told us they were not required to be based on the 1st floor and would instead check on people hour and would then leave the floor. We noted there were no staff constantly based on the 1st floor. The majority of people were assessed as not being able to use a call bell due to their declining health and cognitive impairment. This meant they may not be able to alert staff if needed which placed them at risk.

Staff were supporting people with complex mental health diagnosis’s such as psychosis and schizophrenia but had not received any specialist training around mental health. Systems to assess staff had the skills and competency to administer medications were not robust, and the provider had not conducted physical observations on staff to assess their competency. Staff competency had not been assessed by a qualified person to administer certain injectable medications, and there was not always a competent member of staff site who could do this task which placed people at risk.

The provider had not recruited any new members of staff since the last inspection, therefore we could not review recruitment practices. Staff working patterns were safe and they received days off and breaks when required.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There was a significant odour of urine throughout many parts of the building including the communal lounge and people’s bedrooms, indicating cleaning systems in place were not effective. This left people in profoundly undignified situations and at greater risk of developing infections. Although we saw the provider had identified specific rooms has smelling of urine a month prior to the inspection, the same rooms continued to be deeply unsanitary during our visit. Improvements were also needed to cleaning in areas such as the kitchen and laundry. For example the kitchen bin was uncovered and we saw trays used for cooking we heavily degraded or encrusted with baked on food which meant they could not be effectively cleaned.

Staff we spoke to acknowledged that improvements needed to be made to the cleaning. One staff member told us. “There are lot of things to improve, particularly around cleaning and hygiene”. A relative added “The wee odours have come in, possibly because of less staff”. After our visit, the registered manager informed us a deep clean had been undertaken.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Systems in place were not robust to ensure people would always receive their medications safely, or were being supported by sufficiently trained staff. One person required rescue medication in the event of a seizure and we identified multiple instances where there was no member of staff on shift who had been assessed as competent to administer this. There was unclear guidance on when this medication should be given, and staff gave conflicting accounts of how they would respond to a seizure. This placed the person at a significant risk of harm.

Another injectable medication was being given without the competency of staff to do so safely being assessed by a suitably qualified person. Although staff had conducted online competency checks to assess their ability to administer medications, the provider had not conducted in person competencies to formally observe their practice in this area was safe. Some medications were being given covertly where it can be disguised in food or drink. The provider had not sought formal guidance from the GP or the pharmacy that specific medications would be safe or effective if crushed, which meant there was a risk that they would no longer be effective at meeting the health need they were prescribed for.