The Terrace

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 service was in breach of legal regulation in relation to the safe management of people’s medicines.

This service scored 50 (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. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incident forms did not always provide enough detail to evidence incidents and unexplained injuries, such as skin tears, were investigated. The registered manager did not have effective oversight of accident and incidents meaning opportunities to learn from incident and reduce the risks reoccurrence were missed. Staff told us management did not provide feedback after reporting incidents and some staff were not clear on what type of events needed reporting.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Hospital passports did not always include essential information to support people when leaving the service. This had led to a person being admitted to hospital and becoming distressed as their needs were not met.

New admissions to the service were discussed in weekly clinical review meetings. These discussions often took place after people had already been admitted to the service. This meant there was a lack of assurance their needs could be met appropriately and communicated to all staff prior to admission. Provider expectations were that heads of departments and the registered manager would attend weekly clinical review meetings, but this was not happening in practice.

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. 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 always share concerns quickly and appropriately.

The provider had recently re-issued safeguarding policies to staff and 92% of staff had received online safeguarding training. However, staff told us they did not feel listened to when they raised concerns and did not feel these were acted upon appropriately. They provided examples of safeguarding concerns they had raised. Records confirmed these had not been appropriately reported in line with the safeguarding process.

Staff described a lack of learning culture when there was an incident. One staff member told us, “If staff see something, we will say there is something wrong, but they (management) don’t listen, that’s what upsets me; Then you think, why do you bother saying anything.”

It was not always clear concerns raised had been appropriately investigated and addressed and there was a lack of communication with people raising concerns.

The provider did not always work well with people to understand and manage risks. Improvements were needed to promote positive risk taking in the service to encourage and enable independence and quality of life.

Risk assessments were not always in place to manage potential risks effectively and ensure people remained safe. For example, risk assessments for people taking blood thinning medicines were not in place. People were not always consulted and involved as active participants in their risk assessments and care plans.

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

The environment for people living with dementia needed repairs, redecoration and adaptations to meet people’s sensory and communication needs. Bedrooms were not always personalised and dementia friendly initiatives like memory boxes were not being used outside people’s bedrooms. Memory boxes help people to recognise their bedrooms by evoking memories from their life.

Environmental risk assessments were not always carried out where there was a known risk or impact to people using the service. For example, a hot food trolley was left in a communal area unsupervised which posed a risk of burns and fire. This had not been identified as a potential risk.

Daily management checks had not identified and addressed issues in a timely way, such as faulty fixtures posing a potential risk to people.

The provider took action to address the concerns outlined during the assessment process.

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.

The service used a dependency tool to work out the number and skill mix of staff required. However, actual staffing levels did not always meet the required staffing levels. The local authority has raised concerns regarding staffing levels and although agency staff were now being used overnight to ensure safe staffing levels this initiative was not adopted during the day to cover staff shortages. Staff told us staffing pressures often meant senior support workers went without a break and staff couldn’t spend meaningful time with people.

Staff deployment was not effective. Staff told us 2 senior staff were redeployed from care duties to non-care duties and this was impacting the care staffing levels significantly.

Family members told us they felt there was not enough staff. One relative described how there would be long periods of time in communal areas where there were multiple people without staff supervision.

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. People and their relatives told us they felt the home was clean and tidy. Cleaning checks and regular infection, prevention and control audits were carried out.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not always stored, administered or documented correctly. People were not always given medicines as directed. For example, medicines that had to be given at a specific time or where there were special instructions around administration. We raised this on the day of the assessment and asked for action to be taken. However, for 1 medicine that posed a risk to the person, the provider did not take immediate action to address this concern and seek medical attention.

Creams were not always stored correctly, and there were medicines with worn labels which the instructions could not be understood. Allergies were not always documented correctly. A person was receiving a medicine which they were allergic to, despite this being documented in their records. Some medicines were out of date and opening dates were not always recorded to ensure they remained safe to use.

Staff completed annual medication competency checks. However, medicines training had not been updated, which was not in line with best practice guidance issued by National Institute for Health and Care Excellence (NICE) and Skills for Care.

People who were able to, had not been involved in discussions around their medication administration and preferences were not always documented in risk assessments and care plans.