South Street

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 the service under this provider. 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 safe care and treatment.

This service scored 47 (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. Lessons were not always learnt to continually identify and embed good practice.

We could not be assured that safety events were always being appropriately reviewed for understanding and learning. For example, where incidents had occurred in which people had been exposed to risk and harm, the information documented on incident records relating to learning had either not been completed, had failed to identify there had been learning opportunities where these existed or, when learning was documented as having been obtained, failed to mitigate risks. Furthermore, there was no system in place for leaders to review and analyse safety events that had occurred in order to identify information that could help mitigate future incidents and risks. When this was discussed with leaders, it was acknowledged that the process for reviewing and understanding safety events could be more robust. The failure to ensure an effective system was in place meant people were at risk of safety events not being appropriately managed.

However, staff told us they felt safety events were managed well and relatives said they were made aware of accidents and incidents.

The provider did not always ensure safe systems of care. They did not always manage or monitor people’s safety.

Effective systems were not in place to ensure safety was consistently monitored and managed at the service. For example, as reported elsewhere under safe, some safeguarding, safety events, environmental, staff training, IPC and medicines risks had not been identified or acted upon to ensure people were consistently safe. This meant people were exposed to risk.

While no one had moved into the service recently, the registered manager told us what the transition process was for people before they moved to the service. This included observing people in their previous home, so they were able to observe their needs. The provider said that assessment plans were then developed from this process, which were used to create people’s care plans and risk assessments. This was supported by relatives, who said the process was good and involved themselves.

The provider did not always concentrate on protecting people’s right to live in safety, free from abuse and avoidable harm.

We viewed safety event records which showed people had been harmed as a result of behaviours from another person. These incidents had not been effectively reviewed by leaders, which could have supported understanding and learning of such events. This meant there was an increased risk of recurrence which exposed people to avoidable harm.

There were inconsistencies in relation to reporting safeguarding concerns to external partners such as the local authority and CQC. We found some incidents were reported whereas others weren’t. Not all staff had completed safeguarding training; however, they were able to explain how and who they would report concerns too.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service and found people had up-to-date DoLS authorisations in place.

People did not raise any concerns about feeling unsafe, with one person telling us, “I am happy here, the staff look after me”. Staff and relatives also told us they felt people were safe, with one relative telling us, “My [relation] is really looked after at the home.”

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 ensure people were safe.

We observed people’s care plans and risk assessments did not always provide information which reflected people’s needs and risks. For example, a person’s behaviour care plan did not identify behaviours which the person had displayed and caused harm towards other people. This meant there was no guidance for staff on how they could keep people safe from these behaviours, which exposed people to risk of harm.

However, the information staff told us about other people’s needs demonstrated good awareness of the risks associated with people and how these could be supported. For example, staff told us how they supported a person to leave the service in a way they had not been able to previously. Relatives also told us that staff supported people to reduce risks to their safety.

The provider did not always detect and control potential risks in the care environment.

We were not assured that all environmental risks had been identified and acted upon. We observed radiators and pipework did not have covers and there were no systems in place to ensure the temperature of radiators was checked to protect people from the potential risk of burns. Furthermore, there was not a risk assessment in place to show how radiator temperatures were being managed to ensure temperatures did not reach high levels. However, when these concerns were discussed with the provider, they did put a system and risk assessment in place which provided some assurances that risks were being mitigated.

There was a fire risk assessment in place which had identified a number of issues. When we viewed this information, we saw a number of these issues had not been addressed by the provider. When we discussed this with the provider, they were unable to explain why the issues had yet to be addressed or when this would be the case. However, the provider has since informed us work is being undertaken to ensure that all issues are being acted upon.

Failure to ensure environmental risks were managed exposed people to the risk of harm.

We viewed health and safety checks, environmental audits and service certificates. These checks and audits had failed to identify the environmental concerns listed above; therefore, we could not be assured there was effective oversight of environmental safety.

The staff training matrix showed that most staff received a range of appropriate health and safety training, such as Fire Safety, Moving, Handling and Health and Safety.

The provider did not always make sure there were enough skilled staff.

The service’s training matrix showed some staff had not completed training specific to keeping people safe and meeting their needs, such as safeguarding, learning disability awareness and autism awareness. This meant people were being supported by staff who did not always have the relevant training for their role.

However, we observed staff supported people in a safe way, which included the ways in which they communicated with people and understood their needs. Furthermore, the recruitment records we viewed demonstrated that safe and robust recruitment practices were always carried out.

We observed staffing levels reflected the service rota and people’s care plans, which meant with the additional support of leaders, people could leave the service safely. Relatives also told us they had no concerns with staffing levels.

Staff told us the managers provided support to them when required and records confirmed staff received supervisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We observed faeces on a shower in one of the bathrooms and the surrounding area in and around the shower was in a poor condition, including tiles, walls, and seals. While some of these issues had been identified within a provider audit and had not been acted upon, some of the issues had not been identified by audits. These issues posed a potential infection prevention control (IPC) risk to people who used the service.

However, we saw other parts of the home were clean, staff had access to personal protective equipment (PPE) and most staff had completed IPC training.

The provider did not always make sure that medicines and treatments were safe and met people’s needs.

We observed keys for the home’s medicines fridge left inside the fridge, unsupervised by staff and accessible to people.

Daily medicines were not always administered as prescribed and, where this was the case, there was no information recorded on Medication Administration Records (MARs) or on other medicine records which documented the reasons for this. When this was discussed with staff, they told us reasons for this included people refusing to take their medicines on occasions, staff being unable to locate a medicine for a number of days and a new supply of a medicine not being ordered in time for when it was needed. We also saw some topical medicines did not always have corresponding body maps or other medicine records to provide staff with guidance regarding their application.

’As required’ medicines failed to have corresponding protocols to provide staff with direction regarding their use, and the 1 protocol that was in place contained inaccurate information about the medicine. Furthermore, when these medicines were documented on people’s Medicines Administration Records (MAR) as having been administered, the reason for this being the case was not always documented. This meant we could not be assured that people were beingprovided their ‘as required’ medicines safely and in accordance with best practice and guidance.

Furthermore, not all staff had received medicines training, twice-daily medicines checks were not always being undertaken and the medicine audits failed to identify the issues we observed.

Despite this, the senior staff member we spoke with demonstrated good awareness of medicine processes and relatives did not raise any concerns regarding how the service manages people’s medicines.