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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment, safeguarding people from abuse and safe and effective staffing.

This service scored 31 (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. They did not always investigate or report safety events. Lessons were not always learnt to continually identify and embed good practice. At our last inspection there were failings in ensuring there were adequate systems in place to learn when things went wrong. At this inspection improvements had not been made, and systems were still failing to identify where incidents had not led to reviews. For example, where a person had incidents of distressed behaviour, these had not led to a review of risk assessments and care plans which meant we could not be assured people were safe. In another example, where incidents had occurred with medicines management, staff had not identified and escalated these concerns for review and learning. The monitoring processes in place to learn from incidents had not identified this which meant people continued to be exposed to the risk of harm.

The provider did not establish and maintain safe systems of care. They did not manage or monitor people’s safety. Systems were not being used effectively to keep people safe. The provider had systems in place to ensure people received safe care, however there were numerous examples of where these systems had not been used to ensure people were safe. Safeguarding procedures had not always been followed, and incidents had not always been reported. Incident review procedures were not always used to ensure peoples risk assessments and care plans were updated following an incident. Risk assessments were not always being followed to manage the risks from choking and care plan and risk assessment reviews were not always being completed for skin integrity and behaviours. This meant people were exposed to the risk of harm as processes designed to keep them safe had failed to operate effectively.

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 always share concerns quickly and appropriately. The providers systems for identifying and escalating safeguarding concerns had not worked effectively to ensure all reportable incidents which had happened were reported for investigation by an appropriate body. We saw multiple incidents of assault had not been reported for investigation, and actions to safeguard people from this had not been taken.

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. We found that when needed, DoLS were in place for people. However, where a person who was subject to a DoLS had left the premises without staff knowledge or support, this incident had not been reported to the authorising body. We made referrals to the safeguarding authority to alert them to all the incidents we found which had not been referred for consideration for investigation.

The provider did not 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. At the last inspection risk assessments and care plans did not provide staff with adequate guidance on managing risks to people’s safety. At this inspection we found risks to people were still not being managed safely. Staff were not consistently following advice and guidance in place to protect people. For example, we saw numerous occasions, including on the day of the inspection, where a person had been given food items which were not in line with Speech and Language Therapy (SALT) guidance and the persons care plan. Staff were unable to give clear explanations of what food items the person should avoid to reduce their risk of choking. Whilst the person did not come to any harm, they were exposed to the risk of harm from choking. We also identified staff were not following the risk assessment and care plan for distressed behaviours to reduce a person’s anxiety and prevent the risk of incidents where the person may harm others. This meant the person became anxious and upset and this exposed other people to the risk of harm. Despite these concerns people and relatives told us they felt people were safe living at the service.

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. At our last inspection we found concerns with how the provider detected and managed potential risks to the care environment. At this inspection we found improvements had not been made and people were exposed to the continued risk of harm. Windows in the home did not have tamperproof restrictors in place. There was no risk assessment in place to manage the risk this posed to people living at the service. Despite checks having been carried out on window restrictors which identified this issue, no actions had been taken to make the windows safe. This exposed people living at the service to the risk of harm. After our inspection the provider took appropriate action to address this and informed us all windows now had appropriate restrictors in place. We will check this had been maintained at our next inspection.

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. We saw people did not have their needs met in the way their care plan required. We found staffing levels were insufficient to ensure people’s behaviour management plans could be followed to reduce anxiety which resulted in people becoming anxious and shouting at other people. Staff told us a person’s needs had changed and they required additional staff to support them with their mobility. However, additional staff had not been made available, and they were utilising other people’s 1 to 1 staffing hours to ensure a person had staff available to move them safely. All staff we spoke with told us there was not enough staff to meet peoples needs and ensure they could do things they enjoyed, like going out into the community. Relatives also told us they felt there was not always enough staff to make sure people had their needs met. A relative told us, “No there isn’t [enough staff]. I just feel sometimes because [person’s name] probably isn’t in great need compared to others another staff member would be good to be there for [person’s name]. It means [person’s name] is not able to go out.” Recruitment records were not consistently accurate, and improvements were needed to ensure records followed the providers recruitment policy. However, improvements were noted in how staff training was managed, monitored and maintained as we found all staff had completed their mandatory training and updates. Staff confirmed training had improved and been completed and records supported this.

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. At the last inspection areas of the home had not been maintained which increased the risk of cross infection. These concerns had been addressed at this inspection. However, we saw staff were not consistently disposing of soiled items in the way they should, which exposed people to the risk of cross infection. Further improvements were needed to ensure staff were following the procedures and keeping people safe. However, people and relatives did not raise any concerns with us about infection prevention control procedures. The provider had a policy in place and systems to ensure staff followed safe infection prevention control procedures. Staff had received training in how to follow the procedures effectively.

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. At the last inspection we found concerns with medicines storage and guidance. These concerns had been addressed at this inspection, however further improvements were needed. We saw some examples where medicines had not been documented as taken on people’s medicines administration records. No action had been taken by staff to escalate these incidents and determine if people had received their medicines as prescribed. This meant we could not be assured people were having the support they needed to take their medicines as prescribed. However, people and relatives did not raise any concerns with us about medicines administration.