Thanet House

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 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 legal regulations relating to staffing and fit and proper persons employed.

This service scored 53 (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.

The process for recording incidents was not consistent. Staff completed accident incident reports but due to a change in the way incidents were recorded it was not clear if the registered manager had reviewed each incident and ensured the correct action had been carried out. There had been no analysis of accidents and incidents to identify common themes and trends. Accidents and incidents were not routinely discussed during staff meetings to enable learning across the team.

The registered manager and provider did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They did not always ensure there was continuity of care, including when people moved between different services.

The registered manager told us transitions into the service were well planned with opportunities for several visits before people moved in, however, there were no records of this process for the people currently receiving care, so we were not assured of how consistent and effective this process was.

Pre-admission assessments were conducted before people entered the service, but these were limited in scope and did not constitute a detailed assessment of people’s health and social care needs. People had hospital passports in place which could provide information if people needed to go to hospital however, we found these to be outdated and contained inaccurate information.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff did not always concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Prior to the assessment we received information of concern about staff conduct. The provider has investigated these concerns and taken appropriate responsive action. However, the provider’s investigation found staff did not always understand professional boundaries and did not always manage risks associated with complex mental health needs. This showed more work was needed to ensure effective safeguarding systems and processes were in place.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLs within the service.

Staff received safeguarding training and told us they knew how to raise and report concerns when needed. A member of staff said, “I regularly check on service users toprevent self-harming. If I notice any signs of unexplained marks on a service user or anyone says something that suggests abuse or neglect I listen and reassure the user and respond appropriatelybyfilling an incident report and then report to the manager.”

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

People told us they were not always involved in discussions about their safety and risk assessments did not show people had participated in the risk assessment process or these had been discussed with them. Risks to people were not always identified, assessed, documented and reviewed within their plan of care.

People’s care records lacked detailed information for staff to follow to ensure risks to people were mitigated when taking part in activities and events of their choice. One person required specific mobility support to attend health appointments but there was no mobility assessment in place or guidelines to ensure staff understood how to support the person to attend appointments or access the community safely.

Self-harm risk assessments were in place for people at risk. These included guidance about carrying out checks of people’s rooms to ensure potential hazards were removed however, we found no evidence of these checks happening. We did not find evidence that people had been harmed but the lack of robust monitoring in line with the risk assessment exposed people to the potential risk of harm.

The provider did not always control potential risks in the care environment and ensure equipment and facilities were safe.

The most recent fire risk assessment highlighted the external fire escape had not had an assessment in the last 3 years to ensure it was structurally sound. The risk assessment included a recommendation that a competent contractor should carry out a structural test to ensure it was safe; however, the provider had not acted on this.

A recent internal health and safety audit had also highlighted the need to carry out a risk assessment for the balcony connected to the external staircase. The provider could not provide evidence that any of these recommendations had been acted on to ensure the fire escape and balcony were safe to use.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff did not all receive appropriate, comprehensive training that was relevant to their role.

Although the service specialized in providing care to people with mental health conditions, Autistic people, and people with a learning disability not all staff had not undertaken training in learning disability and autism. Most staff had not received mental health training, and training in managing distressed behaviours.

The provider had started to make improvements and had recently delivered some service specific training in managing obsessive compulsive disorder (OCD) and self-harm. However, due to the considerable gaps in training we could not be assured sufficient improvement had been made at the time of the inspection.

The provider’s governance systems were not effective in ensuring safe recruitment practices. We identified gaps in staff employment histories and found that references had not always been obtained from previous employers.

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.

The premises were visibly clean and hygienic on the day of our inspection and cleaning schedules were in place. This helped ensure the premises were routinely kept clean. Staff wore personal protective equipment when providing support with personal care and had undertaken training on infection control. There was an infection control policy to help guide good practice in this area.

The provider did not always make sure medicines were managed safely. We identified a range of issues with medicine records which had not been identified by the provider’s quality assurance processes.

Medicine care plans contained conflicting information about what support people needed to take their medicines. 1 person’s care plan stated they were independently taking their medicines, but medicine records showed this was not the case and staff were in fact administering the person’s medicines. We also found medicines that were being administered were not always being recorded on the medicine administration chart (MAR). When we asked why one medicine was not on the person’s current MAR we were told it had been discontinued but daily records showed it was still in use at the time of the inspection.

Guidance for PRN (when required) medicines contained misleading information about how staff should assess the need for the medicine. One person’s PRN guidance said there was a detailed risk assessment and pain assessment tool in place which staff should familiarise themselves with. When we queried this with the registered manager, they confirmed the pain assessment tool was not actually required and not in place.

The risks associated with the use of flammable emollient topical creams had not been assessed and there were no guidelines in place to ensure staff and people receiving care knew how to reduce the risks associated with these creams.

Staff competency around medicines was not conducted in line with national guidance. Staff were administering one person’s medicine via a weekly injection but there were no competency assessments to ensure staff were able to carry out this specific task safely and effectively. Generic medicine competency assessments had been carried out for some staff but these had not been reviewed annually in line with guidance. Although people had not been harmed these shortfalls exposed people to potential risk of harm from unsafe medicines administration.

Medicines were stored securely and temperatures of storage rooms and fridges were monitored to ensure they were at the correct temperature. Staff told us they thought people’s medicines were managed safely and they knew what to do if they found an issue. One member of staff said, “If there is medication error the manager is informed, and a call is made to the GP or Pharmacyor 111 for advice.”