Select Lifestyles Regent House

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 regulations in relation to safe care and treatment and the management of medicines.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt, to continually identify and embed good practice.

When incidents occurred, it was not always clear what action was taken. As reported on in involving people to manage risk, when an incident occurred in relation to medicines, the care plans and risk assessment in place had not considered this risk and we saw medicines continued to be stored insecurely, meaning action had not been taken to mitigate further similar incidents from occurring.

However, the registered manager told us, and we saw lessons had been learnt in other areas. This included when safeguarding incidents had occurred, and investigations had taken place. They told us they shared this learning with staff through meetings and supervisions.

The provider did not always ensure, establish and maintain safe systems of care.

There were systems in place to ensure people’s needs were assessed before they started using the service. This included both face to face and record-based assessments. However, people did not always have detailed care plans or risk assessments in place based on these assessed needs. For example, where people required 1 to 1 support for a set number of hours, care plans did not always record what this support should look like and what safety checks were required. We found incidents had occurred when people who should receive 1 to 1 support had been left unsupervised which demonstrated safe systems were not in place.

However, people and relatives were happy with their transitions into the service. One relative described this to us and said, “Assessments were carried out before [name of person] moved in. They were there for respite at first, then they gave the family a moving in date”.

The provider did not always ensure people were protected from the risk of abuse and avoidable harm.

A serious and preventable incident occurred at the service during our assessment which resulted in avoidable harm. The provider took appropriate action in response to this incident and we will check improvements have been made and sustained at our next assessment.

People and their relatives raised no concerns about their safety. One relative told us they felt their relation was safe.

Staff told us and records confirmed they had received safeguarding training. They were able to tell us the action they would take if they had concerns. There were safeguarding procedures in place to ensure concerns were identified and reported.

Risks to people were not always managed in a safe way.

We were alerted to a serious incident that had occurred as staff had not followed 2 people’s agreed care plans, risk assessments and staffing levels needed to keep people safe. This had resulted in harm to a person.

Other risks to people had not always been considered to ensure they followed the right support, right care, right culture guidance. For example, people’s monies were stored in the medicine room at 1 of the supported living schemes, individual risk assessment had not considered the rationale for this, or the individual risks this posed for people.

Records showed there had been an incident related to a person and medicines. This incident had not triggered a review of the risks for the person or other people to ensure the risk was managed safely.

However, we found examples of some appropriate risk assessments that were regularly reviewed, including how people were supported with their mobility needs.

The provider did not always detect and control potential risks in people’s home environments.

People’s environments did not always follow the right support, right care, right culture guidance. For example, we saw people’s front doors were propped open and not locked to ensure their individual environments were secure and when medicines were a risk they were not safely stored.

The registered manager described the process of how people’s homes were maintained. They told us regular checks were completed, and any concerns would be raised with an independent maintenance team who would act.

People and relatives raised no concerns round the environment. One relative told us, “The environment is physically safe. They check in on my relation on the stairs. Doors are locked.”

People did not always receive staffing based on their assessed level of need.

Records showed and we saw that people did not always receive the 1 to 1 support they needed to keep them and others safe. For example, we saw a person’s 1 to 1 support staff was not with them for a significant period of time during our assessment and records showed incidents had occurred when people did not receive their agreed 1 to 1 support. We found that this was because staff were not deployed or managed effectively to ensure they were following agreed plans of care.

We viewed assessment plans that had been completed by the local authority which showed the hours of support people received to live independently in their own homes. The care plans and risk assessments the provider had put into place did not always show how these hours were delivered which meant we could not be assured that the provider was meeting people’s agreed staffing needs. We shared our concerns with the commissioners after our site visit.

We received mixed feedback from staff, people and relatives about the levels of support they received. One relative described to us that their relative would be able to ‘tag along’ with other people when they were on a 1 to 1. This demonstrated to us that people were not always receiving the correct levels of support during their 1 to 1 hours. Another relative felt there were enough staff available when they visited their relation. Staff commented that there were times they felt they were short of staff, and this was usually at weekends or at night.

However, staff told us and records confirmed staff had received training. This included mandatory training and training that was specific to people’s individual needs. We reviewed the training matrix, and this confirmed staff training was up to date.

Staff had received the relevant pre-employment checks before they could start working in people’s homes to ensure they were safe to do so.

The provider assessed and managed the risk of infection.

People and relatives told us staff wore Personal Protective Equipment (PPE). One relative told us, “PPE is used when showering. Gloves and an apron.”

Staff confirmed they had received IPC training and PPE was available to them. One staff member said, “I wear PPE regularly for cooking and personal care. I dispose of it in a black bag then put it in the bin. There is plenty of supplies”. There were processes in place to ensure staff protected people from the risk of cross infection.

People’s medicines were not always stored or transported safely.

Medicines management at the service was not always in line with a supported living model of care. We saw some people’s medicines were stored in a communal medicines room rather than in their individual flats. Because the provider had deviated from the supported living model for medicines management, we viewed the medicines room in line with how we assess medicines safety in other residential services that use communal medicines rooms. We found the temperature of the room was not being monitored. This meant we could not be assured that medicines were safe to administer as the provider had no way of ensuring medicines were stored at the safe and correct temperature in line with medicines manufacturers guidance.

There was also a fridge in this room where medicines were stored, this also had food in it which is not in line with best practice and again the temperature was not being monitored as required, meaning we could not be assured the medicines were safe to administer.

Furthermore, some people’s medicines were stored in the room in an unlocked open topped portable box. This again is not in line with best practice and meant these medicines were not stored or transported to people’s individual flats securely. This also meant there was a risk that people’s medicines could be accessed by people who could tamper or misuse them, placing people at risk of harm.

Some people did have medicines stored in their flats. We viewed 1 person’s cupboard where staff told us medicines were stored, but found there were no medicines in there. The manager told us these had been taken to the office of the supporting living site to count. This meant this person’s medicines were not being stored in line with best practice and did not follow the right support, right care, right culture guidance.

Despite the concerns listed above, records showed people received their medicines as prescribed. When people had ‘as required’ medicines there was guidance in place for staff to follow. Staff administering medicines had received training and their competency was checked to ensure they were safe to administer these to people.

People and relatives were happy with how they received their medicines. One relative said, “Medication is given on time. No medication errors that I am aware of. Medication is in a cabinet, and they have a chart.”