Orbital 4 Support Limited

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 good. At this assessment the rating has changed to 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 fit and proper persons employed.

This service scored 56 (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 a proactive or positive safety culture based on openness and honesty. Staff did not consistently listen to safety concerns, and safety‑related events were not always investigated or reported. As a result, lessons were not consistently learned to support continuous improvement and embed good practice.

We identified an example where a change in a person’s health increased their risk of harm at night. Although the provider had documented the risk and informed the local authority, they had not taken immediate action to reduce the risk, leaving the person at significant risk of avoidable harm. Action to keep the person safe was only taken immediately following the inspection.

Incident recording was inconsistent and there were no robust procedures in place for systematic review and learning. This meant the provider could not be assured they were consistently identifying trends, patterns or recurring themes that may indicate emerging risks to people's safety and wellbeing. We discussed with the provider and registered manager the need to improve how people's needs and risks were documented, and the wider improvements required to strengthen systems and oversight. They acknowledged these concerns and accepted that improvements were needed. They told us they would review and develop their incident management and governance processes to enable more effective monitoring, learning and identification of trends to help protect people from harm.

The provider did not always work effectively with people or healthcare partners to establish and maintain safe systems of care. They did not consistently manage or monitor people’s safety, and continuity of care was not always assured. Although the provider and registered manager took action in response to concerns raised, this did not always demonstrate the involvement of the person receiving care and action taken was not always to the satisfaction of partner agencies involved in their support.

Care documentation did not always contain the relevant information needed to ensure services had a complete and up‑to‑date understanding of each person’s needs.

The provider did not always work effectively with people or healthcare partners to understand what being safe meant to individuals or how best to achieve this. They did not consistently focus on improving people’s lives or protecting their rights to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were not always shared quickly or appropriately leaving people at increased risk of harm or abuse.

The provider had policies and procedures relating to safeguarding people from abuse, and staff had received training and demonstrated knowledge of how to keep people safe. However, systems and processes to protect people from the risk of financial abuse were insufficient. This increased the potential risk of people being exposed to financial abuse due to the lack of effective oversight and lack of knowledge of the provider on managing people’s finances.Information about how people’s individual monies were allocated and how day‑to‑day spending was accounted for lacked clarity. Documentation did not contain enough detail or checks to ensure safeguarding processes were robust.

The provider did not always work effectively with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive or enabled people to do the things that mattered to them. While the provider engaged positively with people, they did not actively involve them in identifying or managing risks. Documentation relating to risk‑based decisions did not demonstrate the person’s involvement or reflect their views. Where risks had been identified, it was not clear what actions had been taken in response. There was no clear focus on developing or reviewing people’s life or care experiences, and opportunities to explore new interests were limited. There was also no evidence that people were being supported to engage in positive risk taking.

The provider detected and managed potential risks within the care environment, and ensured equipment, facilities and technology supported the delivery of safe care. People lived in supported living arrangements, meaning they held their own tenancy and had individual responsibility for aspects of maintaining their home. Staff supported people with day‑to‑day upkeep and helped them maintain a safe living environment.

The provider did not have robust recruitment procedures in place. Employment records lacked essential information, including references and documented checks to ensure staff were safe and suitable to work with vulnerable people. We were not assured that sufficient safeguards were embedded within recruitment practices or documentation to support safe and effective staffing. There were also no effective systems for ongoing monitoring to ensure staff received appropriate support, supervision and development to maintain the skills required to meet people’s needs. This is a breach of Regulation 19 (Staffing) of the Health and Social Care Act 2008.

The provider assessed and managed infection risks. An infection prevention policy was in place and staff had completed IPC training. Staff we spoke with understood the safe use of personal protective equipment (PPE) and during the inspection we observed a clean, hygienic environment.

The provider ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their medicines, including when changes occurred. Medicines were stored and managed safely, and only staff with the relevant training and assessed competencies were permitted to administer them. Medicines records were accurate and reflected what had been given. Where people required ‘as‑needed’ (PRN) medicines, these appeared to be administered in line with their prescribed needs.