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.
 

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 always demonstrate a proactive and positive culture of safety based on openness and honesty. The provider did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider did not have a robust process in place to monitor or review incidents. This meant it was not clear what actions were being taken to mitigate future risks. The provider had not analysed incidents effectively to understand underlying trends and themes. This meant they were not able to demonstrate how lessons were being learnt to improve the quality and safety of care.
 

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. Comments included, “Where documentation, records, or information have been requested, these have been provided promptly” and “They go out of their way to ensure that I am kept up to date and that decisions are made in a smooth way.”

The provider did not always work well with people to understand what being safe meant to them. They did not always 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 demonstrate robust oversight of incidents and safeguarding concerns. Incident reports lacked detail and the language used was not always respectful of people’s rights. Incidents had not always been reviewed to determine whether there were any potential safeguarding concerns. This meant the provider was not able to evidence concerns were robustly monitored and escalated to ensure people were kept safe from the risk of harm.
 

The provider did not work well with people to understand and manage risks. Staff did not always have appropriate guidance in place to provide care that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not have detailed guidance about how to manage risks to people’s safety. Risk assessments contained generic references such as ‘the user’, with limited person-specific information. Risk assessments linked to healthcare needs did not provide staff with clear guidance about what to do in the event of an emergency. Staff were not always able to explain what action they should take. This meant there was a risk people may experience unsafe care.
 

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 make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We identified gaps in the provider’s recruitment practices, with full employment histories not consistently recorded for all staff. Staff had access to a range of training relevant to their roles. However, not all staff had completed or maintained up-to-date training in all areas required to support people safely.

Following our feedback the provider told us they were reviewing their recruitment and training processes to ensure shortfalls were identified and addressed more promptly.
 

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.

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.