Sister Winifred Laver Promoting Independence Centre

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 changed to requires improvement.

This service scored 59 (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. Incidents and accidents were investigated, actioned and reported to relevant bodies.

Since our last visit, the provider had implemented an incident analysis system to help identify lessons. This required further development to ensure as the analysis lacked in-depth investigation to understand what was happening with incidents. Staff gave mixed feedback about communication within the service and felt they were not always kept up to date about changes.

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. They did not always make sure there was continuity of care, including when people moved between different services.

The referral process had been improved to ensure admissions to the service were appropriate. There was now sufficient information provided to determine prospective admissions to the service were suitable for rehabilitation. However, we were unable to fully assess the impact of these changes due to the low number of admissions to the service and a cap on the number of people able to reside at the service, due to some building defects. There remained delays in moving some people into their own accommodation due to the complex nature of their situations, which the wider local authority were addressing. Although care plans had been reviewed and re-written, they needed further development, so they fully reflected people’s rehabilitation needs and aspirations.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Since our last inspection, safeguarding concerns were now being reported and investigated in a timely way. People gave positive feedback and felt they were safe living at the service. A person said, “I like it here, I feel so safe.”

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.

Risk assessments had been completed when needed. However, these required further development to ensure the measures to reduce risk were recorded clearly and in detail. For example, some risk assessments described how staff should respond to an incident when it happened, rather than the measures needed to prevent the risk occurring in the first place.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental risk assessments had been completed. The provider was following advice from the fire service whilst an issue with the fire system was being addressed. As a result, the number of people living at the home had been capped to maintain safety. Health and safety checks were up to date to help maintain a safe environment.

There were sufficient staff to meet people’s needs. Staff were visible in communal areas, so they could support people quickly, when required. A person commented, “They are on the ball. They are here in seconds.” The provider did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. Staff gave mixed views about teamwork, support and communication within the service, which potentially impacted on some people’s care.

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 did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Improvements had been made to the safe handling and administration of medicines. The providers medicines policy had been updated, and staff had signed to confirm they had read the policy. A self-study book had been developed to train staff on the safe administration of medicines and competency assessments had been completed for staff who administered medicines.

Medicines were stored in a central, temperature-controlled treatment room. Temperature checks were recorded for the room and fridge for most days, and all days recorded were within range. Controlled drugs were stored securely with access restricted, and audits were completed in line with the provider’s policy. Keys for accessing the medicines cupboards and trolleys were stored securely and in line with guidance.

Medicines administration records (MAR) had photos of residents to help staff administer medicines safely. MAR charts were handwritten, and each entry was counter signed for accuracy. Each MAR was numbered so staff knew how many MAR charts each resident had.

Residents were encouraged to self-administer medicines and risk assessments were in place to support people to safely reintroduce this process.

Medicines taken ‘as required’ were recorded on the MAR chart and protocols were in place. Further work was needed to ensure when these were administered the reason for administration and the outcome were recorded.

One person was prescribed a time critical medicine. Although the MAR chart stated what time this was to be administered in the instruction area, the administration area did not record the specific time. Therefore, it was not clear if this was being accurately followed. This was discussed with the home’s manager who stated this would be reviewed and improved.

Medicines care plans were generic and not person specific. Work was needed to ensure that the information within the plan was relevant to the person the medicine was prescribed for.

The home had introduced a variety of audits to improve the oversight and accountability for all aspects of medicines handling. These were completed on paper but also uploaded to the computer, as part of the home’s improvement plan. We saw where actions were identified these were logged and acted upon. Where incidents had occurred, learning was completed, and this was shared with all staff at the home, so that everyone could learn from any errors.