Aspire Hub 3

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 require 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 people’s safe care and treatment including medicines.

This service scored 53 (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 consistently maintain a proactive and positive safety culture based on openness and honesty. Lessons were not always learned, and good practice was not consistently embedded.

Although policies and procedures for recording and reporting incidents were in place, our review of accident and incident records showed that, while events were reported, appropriate follow-up actions were not always completed. In some cases, incidents remained unactioned in people’s files.

The provider had undertaken some analysis of accidents and incidents; however, this was incomplete and did not capture all occurrences. As a result, the provider was unable to fully identify triggers, themes, and trends across the service to inform learning and improve people’s experiences.

The registered manager was made aware of these concerns during the assessment and took immediate steps to address them.

The provider did not consistently work with people and healthcare partners to establish and maintain safe systems of care. Monitoring and management of people’s safety were not always effective, and continuity of care was not consistently assured.

Although staff demonstrated knowledge of people’s health needs, we found people were not always supported to attend important health appointments. While we were informed that this had improved recently, these gaps meant people’s health needs were not always managed appropriately. One relative told us, “There have been times when [person] has not been supported to appointments that were important for their health needs; this has improved in recent times.”

Staff demonstrated a strong understanding of confidentiality. One staff member explained, “I would not discuss a person with anyone who did not need to know about them.” During our observations, we saw a staff member supporting a person with their mail. They encouraged the person to open their letter and provided appropriate assistance to help them understand its content and any required actions. This reflected a respectful and professional approach to handling sensitive information.

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

Safeguarding policies and procedures were in place, and staff had completed safeguarding training. Staff were able to describe how they would report concerns and demonstrated an understanding of safeguarding principles. However, we were not assured that staff consistently recognised the importance of taking prompt action to prevent potential abuse or that the provider actively sought this information. For example, we found eight instances where one person had unexplained injuries recorded on a body map, but these were not reported to the registered manager or safeguarded. As a result, no investigation took place, and lessons were not learned. This was brought to the attention of the registered manager who took immediate action.

The provider did not consistently engage with people to understand and manage risks in a way that was both safe and person-centred. In some cases, staff failed to deliver care that fully met people’s needs or supported them in doing the things that mattered most to them. This impacted the overall quality and responsiveness of care.

Care records lacked clarity and did not consistently demonstrate involvement from people or their relatives in risk management. Gaps and contradictions in documentation meant care was not always tailored to individual needs.

Although the provider had a risk assessment and positive risk-taking policy, risk mitigation plans did not cover all known risks. For example, there were no supporting risk assessments for a person’s identified risks relating to catheter care, use of equipment such as a Sara Steady and wheelchair, or bed sensors.

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 were not always supported to keep their home safe and well maintained.

The provider had health and safety policies in place, and a range of health and safety checks were completed by the staff team. However not all checks required were evidenced as being undertaken. For example, there was no evidence of wheelchair checks for a people’s wheelchairs or checks on assistive technology such as bed sensors being undertaken. This meant that there was a risk of harm should these be used whilst faulty or broken.

Appropriate fire checks were undertaken, and person-centred fire risk assessments were in place.

Emergency evacuation plans were in place and provided adequate information to assure us staff had the appropriate guidance to evacuate them from their homes in an emergency.

The provider did not consistently ensure there were enough qualified, skilled, and experienced staff to meet people’s needs. Staff did not always receive effective support, supervision, or development, and teamwork was not consistently strong in delivering safe, person-centred care.

Where agency staff were used to cover staffing gaps, feedback was mixed. Some people felt that agency staff worked well once they became familiar with individuals, while others expressed concern about frequent changes and the lack of knowledge among new agency staff. One relative told us, “Due to staffing shortages, trips had been cancelled, and family members had been requested to support people to health appointments.”

Feedback from people and relatives about staff competency was mixed. While some felt staff lacked the necessary training to meet their needs, others expressed confidence in staff’s familiarity and understanding of their care requirements. Although most permanent staff had received adequate training to carry out their roles, the reliance on agency staff meant care and support were not always person-centred. Agency staff often lacked knowledge of people’s individual needs and preferences, which impacted the quality and consistency of care.

We identified gaps in training related to the safe management of people’s specific health needs, such as catheter care. Additionally, not all staff had received end-of-life care training. The registered manager confirmed this had been implemented for team members who had recently supported a person at the end of their life; however, this had not been cascaded throughout the team. These omissions posed a risk to people’s health and wellbeing.

Supervisions were not consistently carried out as required to support staff in their daily practice and learning. Observation-based supervisions were occasionally undertaken to monitor and maintain expected standards.

Staff recruitment followed the provider’s safe recruitment procedures, ensuring appropriate vetting before employment. Induction processes included shadowing experienced colleagues and completing training in areas such as medication administration, moving and handling, food hygiene, personal protective equipment (PPE), and safeguarding.

The provider effectively assessed and managed infection risks, taking steps to detect and control potential spread and sharing concerns promptly with relevant agencies.

Infection prevention and control policies were in place, and staff had received appropriate training. Staff confirmed they had access to personal protective equipment (PPE), such as gloves and aprons, to reduce the risk of infection. During our observations, PPE was stored discreetly in people’s homes and used correctly.

We also found that staff were completing food hygiene records accurately, including temperature checks for hot and cold food, monitoring expiry dates, and labelling opened items appropriately.

There were good processes in place to obtain medicines, advice, and information on stock availability so that any issues could be resolved promptly. There was a process for ordering medicines in a timely manner to ensure medicines were available for people using the service. There were also arrangements in place to obtain advice during out of hours.

Medicines were stored safely and appropriately in people’s homes, meeting their individual needs.

Medication Administration Records (MAR) were available and used appropriately. Where staff had supported the administration of medicines, MAR chart entries were completed. However, the process to check and record stock quantities on MARs, was not followed as per policy, and there were some discrepancies found. MAR charts did not have peoples allergies documented on them and some handwritten MARs had not been completed correctly. This did not provide assurances that people were receiving their medicines as intended or that they were administered safely. In some cases, the information documented was inaccurate, had insufficient detail or was no longer relevant. This means there was a risk of people receiving their medicines incorrectly or inappropriate information being used to support their care which put them at risk of harm.

PRN protocols were not always in place for PRN medicines and those available did not always give sufficient information to support the administration of PRN medicines or those with a variable dose. This means there was a risk of people not receiving their medicine as intended and their conditions not being managed effectively.

Care plans were not always in place or accurate for people with specific conditions to inform and support care givers on how to manage these. This put people at risk of their conditions not being managed effectively.

Risk assessments for people who had been prescribed emollients were in place and topical administration charts were completed using highlighted body maps to show where topical preparations were to be applied to support administration. Although risk assessments had been completed where needed for people, they had not always been signed by the relevant people, reviewed within the time period stated or updated to reflect any changes. Staff knew how to safely support people who required their medication given covertly. The supporting documentation for covert administration was in place and information to support staff in administering covertly was available.

Audits on medicines were done annually; however, they had not been effective at identifying the issues found on inspection. There were plans in place to increase the auditing frequency to monthly.

Records showed that nearly all staff had completed medicines training and competency checks in line with the policy. A process was in place to report, record, and review medicines related incidents and errors including actions and learnings.