16 King Street Also known as O2 Care

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 safeguarding, safe care and treatment and staff training and development.

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 needed to implement and embed systems to help identify and learn from concerns helping to support continuous learning and embed good practice.

Systems were in place for the reporting of any accidents and incidents. Information within the whistleblowing policy referred to ‘learning culture’, stating “We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.” Whilst the service worked collaboratively with multi-disciplinary teams to address incidents. We found little evidence to show how any learning from such events was shared with staff, helping to improve working practice so people were supported in a safe and consistent way.

The provider needed to develop more robust systems for assessing and planning people’s care, particularly when people moved between different services.

Information was gathered as part of the pre-admission assessment process. We saw senior staff had met with people prior to admission. Information had also been gathered from the healthcare teams. We found some information was conflicting and did not fully reflect a person’s needs and potential risks. This information is essential when making decisions about the compatibility of people living in a small home and the on-going suitability of the placement.

Good evidence was seen of the transition plan used to support one person moving into the home. This was planned over a number of weeks and included day visits as well as overnight stay. Speaking with the person, a family member and healthcare professional the plan had been effective and provided positive results for the person.

Hospital passports had been put in place to support people when moving between services. These included people’s personal details as well as relevant information about their health care needs and support the person may require.

Further work with people and healthcare partners was needed to understand what being safe meant to them and how this was to be achieved so they were protected to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

Staff had completed training in safeguarding adults from abuse, Mental Capacity Act, and deprivation of liberty safeguards. A policy and procedure were in place however this did not reflect the correct legislation for services within England.

People living at King Street were subject to lawful restrictions through the Court of Protection and Deprivation of Liberty safeguards. Changes in support had been explored to lessen the restrictions in place for one person enabling the person to increase their independence. However, we found no evidence to show a best interest meeting had been held, involving all relevant parties and action agreed. The care plan and risk assessment did not include details of any time away from home and what action would be taken in the event the person does not return, ensuring they were kept safe. Whilst drafting the report, we were notified by the local authority of an incident and a delay in contacting the police when the person had not returned as planned. Clear procedures were needed to ensure people are kept safe.

In addition, further evidence was needed to demonstrate conditions stipulated within the Deprivation of Liberty Safeguard, were being complied with. Where conditions may not be achievable at this time, the provider should refer this to the supervisory body for review.

One person we spoke with raised concerns about not feeling safe due to a person’s behaviour and was spending more time away from the home as they felt this impacted on their mental health. Family spoken with repeated the same concerns. This was being addressed with staff and relevant healthcare professionals.

Safeguarding concerns were notified to CQC in line with requirements.

The provider needed to work with people to understand and manage identified risks, so staff supported people in a safe way and enabled people to do the things that mattered to them.

We reviewed the care records in relation to the management of risk. Records did not fully reflect the levels of risk and current concerns in relation to behaviours. Risk management plans required further information in relation to potential triggers and the support required to help minimise such risk. Positive behavioural support plans had yet to be implemented. This information should help staff understand and manage behaviours by identifying their root causes and implementing strategies to prevent them, as well as being supported by training, so consistency in support can be offered. One person told us, “I feel the response from some staff is not always appropriate. They will ring for an ambulance when it’s not needed. I feel they need to give me time and space to ‘regulate’ and then I’ll settle.”

Due to the areas of risk, regular observations were made by staff to check people were safe. Observations were recorded. Where incidents had occurred, reports were completed. As part of the quality assurance process, reports should by reviewed to help identify potential themes along with any action required to minimise/ prevent reoccurrence.

Staff had received training in areas of risk including self-harm and ligatures. A generic risk assessment had been undertaken in relation to ligatures. Whilst this included environmental risks this did not explore other areas, such as equipment that can be used to create a ligature, how to raise the alarm, any equipment required in the event of an incident and training information.

Environmental changes had been made where potential risks had been identified. This included repositioning of window restrictor and new door locks, which can be manually unlocked to allow emergency access.

A fire risk assessment was in place. Staff had undertaken fire training and undertaken fire drills. Daily walkaround sheets where also completed, any environmental issues were recorded and followed up by managers.

The provider detected and controlled potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care.

King Street is a small domestic dwelling. People were provided with a good standard of accommodation. The front door was kept locked as people were subject to restrictions. Communal areas comprised of an open plan lounge, kitchen diner. We found some areas of the home appeared sparce, due to incidents where property had been damaged.

The home had systems in place to check the home environment was safe. Safety certificates were in place for mains gas and electric, small appliances and the fire system. Internal checks were also completed in relation to fire safety, health and safety checks, water temperatures and the management of sharps.

Further training and development were required to ensure staff had the knowledge and skills needed to safely and effectively support the complex needs of people.

A programme of on-line training was provided for staff. Records showed some staff had completed a high number of courses in one day. It was unclear how effective this training was and if any knowledge checks had been completed to assess staff understanding and how this was delivered in practice.

Areas of on-line training included awareness of mental health and learning disabilities. Due to the complex needs of people living at King Street additional training was needed to ensure staff were able to recognise and respond consistently to people’s needs. The new codes of practice in relation to learning disabilities and autism also need to be considered and implemented.

Records showed staff had completed training in Prevention and Management of Violence and Aggression. Information provided included a ‘Learner Observation Assessment Record’. However, we saw no evidence these had been completed to confirm staff were able to effectively use this in practice.

Sufficient numbers of staff were available. Staff recruitment processes were safe. Additional information had also been sought for overseas staff confirming their right to work in the UK.

Team meetings and supervisions were held enabling staff to discuss their work. We were told the provider was funding a member of staff to complete a health and social care qualification, which had been identified through their supervision. Staff felt there was good teamwork and management were described as ‘very supportive'.

The provider managed the risk of infection. Monitoring systems helped to detect and control the risk of it spreading.

All staff were responsible for completing cleaning task. People living at the home were also encouraged to complete tasks with the support from staff.

Policies were in place along with training to support and guide staff in maintaining hygiene standards as well as food safety. Cleaning records were completed and any issues discussed in team meetings, agreeing any action required.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened.

There was a safe system in place for the management and administration of people’s medicines. Administration records were completed and a check of stock was accurate. We found instances of medicines being refused. These had been raised with relevant health care professionals and medicines had been reviewed.

Additional information was provided for ‘when required’ medicines. These could be expanded upon to include further detail about when a medication may be required. However, both individuals were able to ask for medication, such as paracetamol, should they be needed.

Records showed staff had received the necessary training in the administration of medicines. Competency assessments were also undertaken to ensure practice was safe and people received their medicines as prescribed. This was confirmed by staff.