Manor Support and Housing Limited Also known as Koala House Annex

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 regulation in relation to safe care and treatment.

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.

The provider did not always demonstrate lessons were learnt and shared with staff to continually identify and embed good practice.

The registered manager explained how incidents and accidents were investigated and how they shared identified learning outcomes with staff. However, some staff told us lessons learnt were not shared with them.

We reviewed the provider’s incident log; however, some incidents did not yet have identified learning outcomes because investigations were ongoing. It was therefore unclear what changes were implemented in the meantime to ensure safety incidents were not repeated. We raised this with the provider at the time of the assessment.

We saw the provider held regular staff meetings and these included a discussion of a variety of topics, including training, medicine management and updates about people receiving support.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

One person’s care records was not always updated to ensure staff could access the most up to date and accurate information. However, we raised these concerns with the provider. The manager told us they reviewed this person’s care plan following this assessment to ensure this information was clearer. People were supported with regular care plan reviews. Staff demonstrated good knowledge of contacting emergency services when people required support.
 

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

One person told us the provider did not always speak to them in a kind or caring way. Following this assessment, we shared information of concern with the local safeguarding team and the provider. These incidents involved allegations of verbal abuse.

We found staff completed safeguarding training. The provider maintained a safeguarding log with information documented about actions taken and lessons learnt.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
We found 1 person did not have a dedicated diabetes care plan in place. Staff needed to know exactly how to support this person, understand how to manage this condition and recognise signs of a diabetic emergency. There should also be clear guidelines for staff on when to call emergency services in the event of diabetic emergency.
The provider also failed to demonstrate a care plan was in place for one person’s EpiPen. This meant there was no guidance of what action staff should take if the person is unable to do it themself and when to call emergency services. The person’s risk assessment clearly stated staff would be required to administer this medicine. There was no guidance in place on how to manage this risk without a care plan.
Additionally, known risks such as history of medicine overdose were not always managed safely. For example, staff continued to give 1 month supply of ‘as needed’ (PRN) medicine to a person to store, despite previous history of overdose from this medicine. There was no self-administration risk assessment in place between this provider and the person at the time of our visit. This meant this person was placed at risk of avoidable harm.
We shared these concerns with the provider at the time of the assessment. The registered manager confirmed they would review these concerns and the care plans.
 

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’s care plan and risk assessments identified environmental risks. However, we reviewed one person’s daily notes and noted care plans and risk assessments were not always reflective of this person’s individual needs and how to support them in a safe and effective way. For example, one person told us they had requested support from the provider to obtain a fall alarm. We found evidence of this in the person’s care plan. However, the provider was unable to demonstrate what action they had taken to support the person to obtain a falls alarm.

We found the provider completed detailed audits for health and safety, and the environment people lived in.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and development. They did not always work together well to provide safe care that met people’s individual needs.

There was 1 person using the service who required staff to administer their EpiPen in case of emergency. However, the provider told us they do not administer EpiPens within the service; therefore, no EpiPen competency assessments had been undertaken. This meant people’s high-risk conditions and care plans were not in line with staff training and competency. This also meant in case of emergency, this person was at risk of not receiving appropriate responsive care and treatment from staff. We shared these concerns with the provider at the time of the assessment and they confirmed they had now arranged EpiPen training for staff.

Senior staff assessing medicine competencies did not have training to check other staff's competencies. We asked to see any training information for senior staff to be deemed as competent assessors to carry out these checks. The provider confirmed this was not in place and they would look to explore this further.

The provider completed most pre-employment checks. However, we found they had not always ensured they identified gaps in required information relating to satisfactory evidence of conduct in previous employment concerned with the provision of services relating to health or social care, or children or vulnerable adults, and where a person has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why employment in that position ended.

Relatives told us staff are approachable and attentive to their family member’s needs.Records confirmed staff and carers had received training. This included mandatory training and training that was specific to people’s individual needs. Staff also had regular supervisions with the registered manager.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider completed monthly infection prevention and control audits with observations. We saw staff completed training in this area. People confirmed staff used personal protective equipment correctly and safely when providing care and treatment.
 

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

The provider did not ensure ‘as needed’ (PRN) medicines had protocols in place. The provider had not ensured PRN protocols were in place to provide staff with clear guidance about when medicines should be administered, the signs and symptoms to look for, and how medicines should be used safely. They should be administered as intended by the prescriber. The care plan should include details about what condition the medicine is prescribed for, dose instructions, signs or symptoms to look out for and when to offer the medicine and in what order to administer medicines where more than one PRN medicine is available for the same condition.

Although staff supported 1 person with their medicines, there was no medication administration record (MAR) in place. Therefore, there was risk of poor medicine management and monitoring of people’s medicines due to lack of documentation and recording. There was also risk of medicines being administered incorrectly due to lack of clear guidance from healthcare professionals.
Additionally, we found staff were filling dosette boxes, which demonstrated secondary dispensing. This is not good practice because secondary dispensing removes vital safety checks and increases the risk of errors. This was also not in line with the provider’s own medicine management policy which stated all prescription medicines must be provided and contained within the original pharmacy produced labelled packaging or pharmacy filled monitored dosage system. Although this medicine was administered in this way due to the person’s preference, the provider did not demonstrate they completed and reviewed relevant risk assessments and had a standard operating procedure in place to manage this method of administration.