Choice Supported Living - East

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding and staffing.
 

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not consistently investigate, report or learn from safety events. Lessons were not learnt to continually identify and embed good practice.

There was limited evidence that the cause of accidents and incidents had been investigated to help ensure actions would be taken to prevent recurrences. When people had required medicinal support to manage their emotional wellbeing, we did not see evidence these incidents were reviewed to identify causes, triggers or themes that would support more effective risk management.
The provider had not identified all potential safeguarding incidents and taken appropriate action in response.

The provider told us there was a system in place to feedback to staff on safeguarding concerns. However, staff told us they reported safeguarding concerns to their line managers and they were not kept up to date on progress or informed of the outcomes. This did not demonstrate there was an effective shared learning culture embedded into the service to identify and learn from incidents. Furthermore, this indicated poor oversight, lack of effective incident/accident management and a failure to embed learning into practice.

We reviewed staff files and found regular supervisions, appraisals and spot checks were not in place for all staff. This demonstrated learning from incidents was not effectively shared and implemented into staff learning to ensure people received safe care and treatment. Throughout the assessment, Inspectors identified and raised significant risks to people. These risks were then only addressed when raised by inspectors. The provider did not demonstrate they took immediate action at the time of the assessment when concerns were first raised to immediately mitigate risk of harm to people.
 

The provider did not always effectively manage and monitor risks to people’s safety or ensure continuity of care.

During this assessment, we identified compatibility concerns between people living together. Records and observations identified incidents which included people entering other people’s bedrooms or bathrooms, unwanted physical contact, arguments and physical altercations. The provider demonstrated that some of these risks were known and that measures had been put in place to manage them. However, incidents continued to occur, and the evidence did not consistently demonstrate that compatibility and associated risk management arrangements were effectively reviewed following incidents to determine whether existing measures remained sufficient to keep people safe.

The provider told us the local authority completed compatibility assessments. However, the evidence available did not consistently demonstrate how the provider reviewed compatibility once people were living together, particularly when incidents or changes indicated that existing arrangements may require further review. This meant the provider could not always demonstrate that compatibility risks were being effectively monitored and reduced. One staff member told us, “You also find out when someone moves in, when they're compatible or not, because the information you get given on a piece of paper, is sometimes not the reality. So, when you start living with someone, it throws up different scenarios for that individual.”

We also identified concerns regarding people’s experience of continuity of care. One relative told us, “They have changed all the staff, 80% in last few months. There is no rota to say who is coming in each day. Half the time the staff don’t know. Not good enough for me or my daughter. Need some consistency.” During our visit to this person’s home, we observed them asking staff who would be on shift the following day. Staff were unable to tell them. The provider subsequently told us this resulted from a misunderstanding regarding the online rota and that printed rotas had since been introduced. However, at the time of our assessment, the person was unable to obtain information from staff about who would be supporting them the following day. This did not demonstrate that the person experienced consistent and predictable care.

The provider did not always demonstrate that safeguarding concerns were consistently recognised, reported, investigated and acted upon to protect people from avoidable harm.

We found examples where staff had not recognised potential safeguarding concerns or had not taken appropriate action to ensure these were recorded, reviewed and, where required, reported to relevant external agencies. The registered managers were also unable to demonstrate that all safeguarding concerns had been reported to the Care Quality Commission (CQC) without delay where a statutory notification was required.

Staff told us about an incident involving interaction between 2 people which resulted in one person becoming distressed. We were unable to identify a corresponding record of this incident within the information reviewed. This meant the provider could not demonstrate that the incident had been appropriately recorded, reviewed and any necessary action taken to reduce further risk.

We also identified concerns regarding the oversight of PRN medicines used to support a person’s emotional wellbeing. Records showed that PRN Lorazepam had been administered 9 times during one month, at 18:00 on each occasion. We also identified a separate period where the medicine was administered on several consecutive days and, on one occasion, twice on the same day. Despite the frequency and pattern of administration, we did not see evidence demonstrating that this had prompted sufficient review to consider potential causes, triggers or themes, whether the medicine remained appropriate, or whether changes to the person’s support or risk management were required.

These findings demonstrated that the provider’s systems did not always identify and respond effectively to potential safeguarding concerns and emerging risks.
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Where previous incidents had occurred, we did not see evidence people’s care plans and risk assessments had been updated to reflect identified risks and learning outcomes. For example, 1 person’s sleeping plan referred to pending occupational therapist and physiotherapy advice rather than current guidance. Escalation arrangements following falls and behavioural incidents required more detail. The person had also had 3 falls in the month according to their care notes.

Another person needed emergency rescue medicine in case of a seizure. We visited the person’s home and found staff had taken the person out but left this rescue medicine at home. This placed the person at potential risk of harm whilst out in the community.There were also concerns staff were not adequately trained to manage specific risks to people. For example, we found 1 person’s care plan stated staff supported them with PEG feeding. PEG (percutaneous endoscopic gastrostomy) feeding is a clinical procedure that can be delegated to a trained care worker or personal assistant by a registered healthcare professional. We did not see supporting evidence that this delegated task was overseen by a healthcare professional and that staff carrying out this task were trained and competent to do so.

The training matrix demonstrated training was in place for staff. However, one relative expressed their concern about staff training based on their observation. One relative said, “No idea what training they have, not told anything about that. I know a lady came in shadowing for 2 days then was on board on an overnight sleep on her own. I don’t know what experience she has.”
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider failed to evidence risk assessments of people’s homes were completed to ensure the safe delivery of care. For example, 1 person using the service had PICA. This is an eating disorder where a person eats things that are not food. The service manager told us all false planting had been removed from inside the house to keep the person safe in this environment. However, during our visit to the home, we found false planting inside the house, along with various other small items placed in every room which could cause harm to this person. The provider could not demonstrate how this risk was effectively monitored and managed.

During 1 visit, the Inspector had to intervene to help 1 person safely manage an immediate risk of harm to themselves. Staff were not present at the time in the kitchen, and this person was left making tea and had a mug of boiling water; they asked the Inspector to hold the mug for them whilst they stirred in their milk. If the Inspector had not intervened, there was risk of the person spilling boiling water over themselves. During our visit we also found a large and dangerous kitchen utensil was being used as a doorstop. We requested the staff member to immediately remove this for people’s safety.

Relatives also expressed their concerns about the environment. One relative said, “There is only so much 1 person can do I do agree with them. You do think it needs an extra person to help and do a bit of cleaning.”
 

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The provider was unable to demonstrate staffing levels, skills, and deployment were always reviewed and adapted to meet changing needs. The provider told us they had tools in place to determine safe staffing levels.

The service supported many service users with complex health needs such as diabetes and epilepsy. We spoke to staff regarding people they supported. Staff could not demonstrate knowledge and competence of managing rescue medicines and ensuring people would be supported in times of an emergency. Relatives also told us how staffing changes impacted their family member. One relative said, “The change in staff is not good for [person] and [person] has a lot of behaviour problems. Having [person] home a bit more so [person] has a bit more normality.”

Staff told us they did not know what ‘IDDSI’ was. This is the International Dysphagia Diet Standardisation Initiative (IDDSI) which is a global, standardised framework used to describe texture-modified foods and thickened liquids for people with swallowing difficulties (dysphagia). At the time of our visit, at least 2 people required support by staff to prepare their food to an IDDSI level. Staff also confirmed to Inspectors that no training had been given to them for this and we found no guidance in the folders at the home. This placed people at avoidable risk of harm because staff had not received training and could not demonstrate the knowledge required to prepare food safely to prescribed IDDSI levels.

Other staff we spoke to told us they needed more training for supporting people with learning disabilities and autistic people. One staff told us they had not been trained in diabetes despite needing to support someone with this need.

Throughout our visits we found several incidents of lone staff working. We found 1 staff was expected to support from 3 to 5 people alone for long periods of time. On 1 occasion we found 1 female staff member was left alone to support 4 male service users, 1 of which had been assessed as a risk to females. Additionally, 1 of these people also had epilepsy and would require staff to administer rescue medicine. One person also required 1:1 support in the community but could not go out due to staff shortages. These staff shortages were found in multiple homes we visited. Staff told us they raised concerns to their managers about staffing and were told there was nothing that could be done.

During a visit, Inspectors had to intervene and contact a manager to request immediate support for a staff member who had been left alone to support 3 people with high risk needs.
 

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

The staff training matrix record demonstrated staff had completed training in infection prevention and control (IPC). After the assessment, the provider sent us their IPC audits.

We observed staff wearing personal protective equipment gloves. However, these gloves were left on when completing different tasks. We therefore could not be assured they were always changed in line with best practice.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There was a lack of guidance and body maps for people using topical medicines. This increased the risk of medicine errors or adverse reactions. Furthermore, some people were using emollient creams. These types of creams are a fire risk when they transfer onto fabrics and dry. The provider failed to ensure appropriate risk assessments were in place to identify associated risks and mitigate these for people’s safety.

As needed (PRN) medicines did not have clear and detailed protocols in place to ensure the safe administration and monitoring of medicines. For example, 1 person had a prescribed epilepsy rescue medicine in case of emergency. There was no medicines protocol in place for this medicine to ensure staff had accessible guidance on when and how to administer, monitor its effectiveness, or seek urgent medical assistance. Another person’s PRN protocol contained 2 very different medicines on the same protocol, despite the medicines being used for different needs.

We reviewed people’s medicine administration records (MAR) and found gaps for several people. The provider did not demonstrate effective quality assurance systems had identified and addressed these concerns.