GreyInsights

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• 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 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 people’s safe care and treatment and safeguarding.

This service scored 28 (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. Lessons were not learnt to continually identify and embed good practice. We found that incidents and accidents had not consistently been reviewed or investigated appropriately. Learning from this was not being consistently captured, shared, or used to inform improvements in practice. Opportunities for reflection and analysis of incidents were not undertaken, which could contribute to repeated occurrences.

The provider did not always work with partner agencies to ensure safe care. Information was not always shared with appropriate professionals in a timely manner which did not allow different services to provider support. For example, provider agencies fed back that they did not always get notified of incidents in a timely manner, which meant there were delays in partner agencies reviewing people’s care. The management team made steps in developing a better communication pathway between partner agencies.

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 provider did not consider the restrictive practices that were in place when supporting people. This meant people had restrictions imposed on them without legal justification or any discussion as to why it was necessary to restrict them.

We found safeguarding incidents had not been notified to the CQC, including serious concerns such as the use of medicines and physical intervention. This lack of governance and failure to monitor the management teams’ performance during this time reflects poor oversight. Similarly, notifications required under regulation had not been consistently submitted, and in some cases, there were delays in notifying CQC. There was no evidence of best interest decisions in place where restrictions were imposed, which resulted in people being unlawfully restricted.

Restrictive practices were observed: use of CCTV, locked rooms and restrictions with food. Relatives felt they needed more reassurance that their relative was safe.

People were not supported to help understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive. There were significant gaps in risk management, medicine administration, incident reporting, and fire safety, all of which placed individuals at risk of harm.

Risk assessments were not sufficiently robust to ensure people’s safety. We found that staff supporting individuals with complex health needs, such as epilepsy did not have all the information they needed in care plans and risk assessments to help support the staff in the event of something occurring. This presents a significant risk to people. Additionally, where people had risks associated to their mental health and self-harm their risk assessments lacked clarity and failed to provide clear guidance for staff on how to respond if an incident occurred. We found discrepancies between the care plan and risk assessment, where the documents did not triangulate. This meant we could not be confident that staff would take appropriate action if this occurred.

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

People were supported to ensure they lived in an environment that met their needs. However, environmental standards required attention, with areas of the home found to in need of maintenance, including visible damage to ceilings and kitchen facilities. The management team reported that they are working with the appropriate people to address this.

Weekly health and safety checks were not being carried out this included fire tests and evacuation drills. Risk assessments for moving and handling, Control of Substances Hazardous to Health (COSHH), infectious diseases, and lone working were not in place. During the inspection an external fire risk assessment was carried out where they found a number of immediate actions required to be taken regarding the environment, staff training and equipment. The management team took immediate action to remedy this.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not 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.

Staff felt they had the right training to support people. However, records reviewed found that the provider did not make sure there were enough qualified, skilled and experienced staff.

Staff training and competency assurance required significant improvement. Although staff reported feeling adequately trained, the evidence provided did not consistently demonstrate that staff were competent to meet the needs of the people they support. For example, Individuals required staff to have knowledge of their needs such as communication needs and their specific diagnosis, yet no staff had received training in this. Learning disability and autism training had not yet been delivered. The provider acknowledged this and confirmed that improvements were planned, with updated training to be rolled out in the coming months.

The provider operated a recruitment process; appropriate checks were undertaken to help ensure staff were suitable to work at the service. A disclosure and barring service (DBS) check and satisfactory references had been obtained for all staff before they worked with people. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Staff supported people to maintain their homes to be clean and tidy. Although the provider had policies which detailed the need to complete audits to check the services with regards to infections prevention control, they did not follow these which means they did not have oversight of the risk of infection prevention and control.

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.

Medicines and treatments were not consistently managed in a way that ensured safety or aligned with individuals’ needs, capacities, and preferences. People were not actively involved in planning their care.

There was insufficient assurance that one individual consistently received their prescribed medication as intended. At the time of inspection, PRN (pro re nata – “as needed”) protocols were not consistently in place. For instance, a mood-altering medicine was administered on multiple occasions without any documented rationale in the daily records and no evidence of any de-escalation strategies or alternative interventions attempted prior to administration. This meant we could not be assured that staff were using the medicines to manage someone’s mood and behaviour.

Furthermore, staff lacked appropriate training in the administration of emergency medicines for allergies, which posed a significant risk to individuals’ health and safety.