Bamburgh Supported Living

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 inspection we rated this key question good. At this inspection 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 provider was in breach of the legal regulations in relation to safe care and treatment and safeguarding.
 

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 promote a proactive and positive culture of safety based on openness and learning. Safety concerns were not always recognised, investigated or appropriately escalated. Incident reports were poorly completed and did not consistently demonstrate appropriate action had been taken to respond to and mitigate risks.

The provider’s oversight of incidents was not effective. Managers had not identified concerns in the quality of incident reporting, and lessons learnt were not consistently recorded. The provider was not able to evidence meaningful analysis of incidents, trends or themes to support learning and improvement. This meant they could not demonstrate appropriate action had been taken to reduce the likelihood of similar incidents occurring in the future.
 

The provider worked well with healthcare partners to establish and maintain safe systems and transitions between services. The provider shared information with other health professionals to ensure there was continuity of care when people were accessing different health services. We received positive feedback from health professionals who worked alongside the provider. One health professional told us, “Communication with professionals is collaborative and proactive, contributing to well-informed decision-making.”

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

The provider had not established effective systems to safeguard people from the risk of abuse. During the inspection, we identified safeguarding concerns which had not been recognised, reported or escalated by the provider prior to our visit.

The provider had not embedded a culture where safeguarding concerns were recognised and acted upon. Concerns relating to staff practice had not always been identified, and not all staff had completed up-to-date safeguarding training. The provider could not demonstrate they had effective systems in place to identify safeguarding risks and take timely action to protect people from the risk of harm.
 

The provider did not always work well with people to understand and manage risks.

The provider assessed and documented risks to people's health and safety. However, some risk assessments did not contain clear and detailed guidance for staff on how risks should be managed. For example, we found an epilepsy risk assessment which did not provide clear instructions on when staff should seek emergency medical advice. This meant staff may not know how to respond appropriately to ensure people received appropriate treatment.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment supported the delivery of safe care. Staff completed regular environmental health and safety checks to identify issues and reported any concerns appropriately.

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

The provider’s recruitment processes were not always robust and we identified minor gaps in the provider’s employment checks. Staff had access to a range of training relevant to their roles. However, not all staff had complete and up-to-date training in all areas required to support people safely. We received mixed feedback from staff about whether they had appropriate training for the needs of the role, particularly when supporting people during incidents of distress.

We also received mixed feedback about whether there were appropriate staffing levels in the services to ensure people and staff remained safe at all times.
 

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 when required.

The services were clean and homely. Staff had received infection prevention and control training and had access to appropriate personal protective equipment [PPE] if required. There was an infection prevention and control policy in place for staff to follow.
 

The provider made sure that medicines were safe and met people’s needs, capacities and preferences. People’s medicines records were up to date and staff had recorded the administration of medicines appropriately. The provider had a medicines policy in place and completed regular medicines audits.