Bedford Road

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 the support and training staff received to fulfill their role.

This service scored 62 (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 had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff recorded and escalated accidents and incidents appropriately. The management team held debrief sessions with care staff following safety events. Lessons learned were shared among the staff team to promote good practice and improve safety. Staff spoke about the changes made and measures implemented following certain incidents, demonstrating a positive learning culture.

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.

Staff involved people, their relatives and relevant professionals in decisions about people’s care and needs assessments, and ensured information was shared appropriately to minimise disruption. The service maintained clear records of people’s healthcare activities and follow-up care. This supported continuity of care when people accessed healthcare services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood their responsibility to report concerns and were familiar with their whistleblowing policy. After describing how they would report a safeguarding concern, a staff member commented, “If I see there's nothing being done, I can call CQC or safeguarding [local authority].” Feedback from relatives indicated people’s rights and wellbeing were safeguarded at the service.

The provider sought the appropriate legal authorisations where people were deprived of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had worked with people for several years and had developed a good understanding of their needs and associated risks. They adhered to control measures while ensuring people could take part in different activities and exercise their independence as much as possible. Following a choking incident, the provider made a referral to the speech and language therapist (SALT) for assessment. The SALT recommended a modified-texture diet, which we observed staff following.

The provider was in the process of updating people’s care records and converting them to electronic records. Consequently, some risk assessments had yet to be updated or were incomplete. However, the management team ensured that any changes to people’s needs and risk reduction guidance were communicated effectively to staff. They told us they would make sure risk assessments were reviewed and updated accordingly.

The provider did not always detect and control potential risks in the care environment.

We identified some environmental concerns that posed a risk to people’s health and safety. These mainly related to unsecured furniture and uneven door thresholds, which potentially presented a trip hazard in the context of people’s individual and changing needs. There were other aspects of the building that required maintenance, including areas around doorways and along various edges where the finishes required attention. Some of these issues had been reported to the maintenance team; however, our evidence indicated that there were delays in addressing them.

The provider carried out various environmental checks, including gas safety, electrical installations, water systems and fire safety. Following our inspection visit, the provider had addressed some of the concerns and put arrangements in place to monitor the progress of outstanding works.

While the provider maintained safe staffing levels and supported staff in their roles, training systems did not always ensure staff received appropriate training and development.

The training matrix showed some staff had outstanding training in areas including safeguarding, infection prevention and control, medicines, food safetyand Oliver McGowan statutory training for people with learning disabilities and autistic people. Training records were not sufficiently clear to establish when some staff had last completed relevant training. There was also limited evidence of staff competency assessments to demonstrate that staff had the required knowledge and skills in areas where training was outstanding.

The management team was aware of some of the gaps and had taken action, including arranging training dates and implementing action plans and risk assessments for some staff. However, there was insufficient evidence to demonstrate that these measures were effective in mitigating the risks associated with the training gaps.This was of particular concern given the additional concerns identified in areas including infection prevention and control as staff were not following good practice guidance in relation to hand washing. This would not have normally happened if staff have had effective training.

The provider ensured there were enough staff to meet people’s needs. In addition to the core staffing team, a group of activity staff supported people to take part in activities and provided additional support to the core team when needed, including with personal care and eating and drinking. Staff received ongoing support through supervision and appraisals. Staff had been supporting people for several years and had a good understanding of their individual needs.

The provider operated safe recruitment systems to ensure appropriate checks were completed before staff started work.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We found cloth towels and bars of soap in communal bathrooms, presenting an infection prevention and control risk due to the potential for contamination through shared use. Handwashing facilities were available for food handling, but it was not clear which facility staff should use, and staff could not confidently identify it to us. This created a potential risk of poor hand hygiene and cross-contamination during food preparation.

We fed these issues back to the management team. They clarified the handwashing arrangements in the kitchen and said they would reinforce these with staff. They explained the challenges regarding the misuse of paper towels and handwash gel in communal bathrooms but recognised the risk of cross-contamination and said they would explore alternative options to reduce this risk.

The premises, including communal areas, the kitchen, kitchen appliances and bedrooms, were visibly clean. This indicated staff adhered to a suitable cleaning routine. Staff had access to and used personal protective equipment as required.

The provider made sure that medicines were safe and met people’s needs, capacities and preferences.

Medicine administration records were clear and contained no gaps. Staff carried out regular stock checks of medicines. There was guidance in place for medicines prescribed to people on a “when required” basis, such as painkillers. The provider was reviewing staff competency to administer medicines at the time of the assessment. Records demonstrated people had their medicines reviewed by appropriate healthcare professionals when needed. This helped ensure people’s medicines remained appropriate to their individual needs.