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• 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 Requires Improvement.

At this assessment the rating has remained 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.
 

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 did not consistently demonstrate a proactive and positive culture of safety based on openness, transparency and learning. Staff did not always recognise, report or escalate safety concerns appropriately, which limited opportunities to identify risks, investigate incidents and embed learning to improve outcomes for people using the service.

The provider had recently introduced changes to its incident reporting systems and processes to support the identification of themes, trends and patterns relating to safety events. However, these changes were at an early stage of implementation and had not yet resulted in consistent reporting practices across the service.

Although we saw examples of incident and accident audits being completed, we found incidents were not always reported in line with the provider's procedures. For example, a person with complex needs had injured a member of staff during the provision of personal care. This incident had not been formally reported and had not been identified through the provider's auditing processes. As a result, opportunities to review the circumstances of the incident, identify potential triggers and implement safe management strategies to reduce the risk of recurrence had been missed. This was also identified at the last inspection.

We discussed this with the registered manager during the inspection. They recognised the shortfall and told us they would address this with the staff team and take appropriate action to strengthen incident reporting processes. This would support improved oversight, promote organisational learning and help ensure lessons were learned to enhance the safety of both people using the service and staff.
 

The provider did not always work effectively with people and healthcare partners to establish and maintain safe systems of care. Systems for monitoring and managing people's safety were not always effective.

The provider did not have robust processes in place to identify, monitor and respond to risks within the service. For example, concerns relating to the management of safety events, safeguarding, and staff understanding and application of the Mental Capacity Act 2005 (MCA) had not always been reported by staff as an incident or identified in managers’ audits which meant they were not addressed promptly. As a result, people were exposed to avoidable risks and were not always protected from the potential for harm.

People and their relatives told us they had been involved in planning arrangements before moving to the service. One person told us staff had met with management prior to the commencement of their care to discuss their needs and preferences. We also found that a small team of staff had received specialist training before supporting a person with complex needs, helping to ensure they had the skills and knowledge required to provide appropriate care.

The provider was able to describe its admission and transition processes for people moving into the service. This included gathering information about people's health, care and support needs from relevant professionals and others involved in their care to help ensure this information was accurately reflected within care records and support plans.
 

The provider did not always work effectively with people and relevant partners to understand what being safe meant for individuals or to ensure concerns were shared appropriately and without delay.

The provider had not consistently recognised, managed or reported safety incidents that had affected people's health, safety and welfare. Incidents were not always investigated or managed effectively to reduce the risk of recurrence. As a result, people were exposed to avoidable harm.

Whilst the provider told us staff did not use physical restraint, care records we reviewed for a person, documented an incident in which a staff member sustained an injury whilst supporting a person with personal care during a period of heightened distress.

The provider had not demonstrated they had fully considered whether the support arrangements in place were restrictive, necessary and proportionate, or whether any restrictions amounted to a deprivation of liberty requiring appropriate legal authorisation.

We found some incidents which met the threshold for safeguarding referral had not been reported to the local authority safeguarding team or notified to CQC as required. This limited external oversight and meant we could not be assured appropriate action had been taken to safeguard people or mitigate future risks.
 

The provider did not always work effectively with people to understand, assess and manage risks associated with their care and support needs.

People's care plans did not always contain accurate or sufficiently detailed information about their needs and associated risks. For example, care records did not consistently provide clear guidance regarding people's emotional wellbeing, behaviours that may challenge, physical health conditions, mobility needs or risks relating to their safety and welfare. This meant staff did not always have access to the information required to support people safely and consistently.

Where people experienced periods of heightened emotional distress or behaviours that could place themselves or others at risk, there was limited guidance available for staff on how to respond appropriately. The impact of this was partly mitigated by the fact that people were generally supported by a consistent staff team who knew them well. However, during periods of staff absence or annual leave, replacement staff may not have had sufficient information about people's individual needs and preferred approaches to care. This exposed both people and staff to an increased risk of harm.

We saw evidence that referrals had been made to healthcare professionals. However, there were occasions when opportunities to seek specialist advice or intervention were not acted upon in a timely way. As a result, people may have experienced avoidable anxiety and distress. Timely intervention may have improved outcomes and reduced known risks to the person.

Staff told us they had a good understanding of the risks associated with the people they supported and felt able to raise concerns with the registered manager. Staff said the registered manager was responsive and provided guidance when concerns were identified. However, the provider’s current systems and processes did not assure us there was effective oversight or documentation of concerns.

Feedback from people and their relatives was generally positive about the support they received. One family member told us, "They always ask me what is best to do if they are unsure, and I tell them." Other people told us they felt involved in decisions about their care and that staff understood how to support them safely.
 

The provider detected and managed potential risks within people's home environments to support the delivery of safe care and treatment. They took steps to ensure equipment and facilities were safe and suitable for their intended use.

Environmental risk assessments were completed before care commenced and reviewed at regular intervals. These assessments considered a range of potential hazards within people's homes, including lone working arrangements, lighting, pets, access to the property and the safe use of household equipment.

Staff received health and safety training and demonstrated a good understanding of how to identify and respond to environmental risks. They were able to explain how they monitored the safety of people's home environments and any equipment used to support their care, reporting concerns when identified.

The provider completed spot checks of staff practice within people's homes to help monitor the quality and safety of care being delivered. Records showed no concerns had been identified through these checks at the time of our inspection.
 

The provider ensured there were sufficient numbers of suitably recruited, trained and competent staff available to meet people's individual needs safely and effectively.

Recruitment records demonstrated the provider had followed its recruitment procedures for all staff employed by the service.

Appropriate pre-employment checks had been completed, including obtaining references and verifying staff members' suitability to work in care. Staff completed a comprehensive induction programme, which included both online and face-to-face training, before providing support to people.

The service was largely staffed by care workers employed under visa sponsorship arrangements. The manager described how they supported staff to settle into their roles, including helping them understand local customs, culture and expectations of care practice. This helped staff integrate into the workforce and provide person-centred care.

The provider was able to demonstrate contingency arrangements to help ensure continuity of care in the event of changes to staff members' right-to-work status. This supported the provider's ability to maintain safe staffing levels and minimise disruption to people's care and support.
 

The provider assessed and managed the risk of infection to help protect people, staff and others from the spread of infection.

Staff had received training in infection prevention and control (IPC) and were able to describe the measures they took to reduce the risk of cross-contamination when providing care. Supplies of personal protective equipment (PPE) were available and were observed at the provider's office. Staff told us they had access to sufficient PPE when required.

People and their relatives confirmed staff used appropriate PPE when providing care and maintained good standards of hygiene. One relative told us staff consistently wore gloves and aprons when supporting their family member.

The provider had an IPC policy in place which outlined expected standards of practice and provided guidance for staff on preventing and controlling the spread of infection.
The provider monitored staff practice through spot checks and supervision processes to help ensure infection prevention and control procedures were being followed.

We were assured the provider had systems and processes in place to prevent and control the risk of infection
 

The provider did not always ensure medicines and treatments were managed safely and in a way that met people's needs, preferences and individual circumstances.

Written guidance was not always available for staff to follow when administering medicines prescribed on an 'as required' (PRN) basis. PRN protocols help ensure staff have clear information about the circumstances in which medicines should be offered or administered, the expected outcomes, and any risks associated with their use.

Staff told us that most people were able to request PRN medicines themselves, such as pain relief, when they needed them. However, we found 1 person who had PRN medicine prescribed to support periods of heightened emotional distress or behaviours that may challenge. There was no written guidance available to support staff in determining when this medicine should be administered.

This meant staff may not have responded consistently to the person's needs and there was a risk the medicine may not always have been administered appropriately.

We discussed this with the provider during our assessment, and they took immediate steps to rectify the issue.

People told us they were satisfied with the support they received with their medicines. They said staff prompted them to take their medicines when required and checked that medicines had been taken as prescribed.

The provider had systems in place to support the safe administration of medicines. Medication Administration Records (MARs) were audited monthly, and the provider was in the process of transitioning to an electronic medicines management system.

Staff received medicines management training and their competence to administer medicines was assessed regularly, including through annual competency assessments.
Despite these systems, gaps in PRN medicines guidance meant the provider could not always be assured medicines were managed in a safe and consistent manner.