Bognor Regis

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 as requires improvement. At this assessment, the rating has remained 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 regulations in relation to people’s safe care and treatment and protecting people from avoidable harm.

This service scored 47 (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 listen to concerns about safety and did not always investigate and report safety events. Action was not always taken to understand why a person had become distressed or why an incident occurred and what could be changed to prevent further occurrences. Risks associated with closed cultures had not been identified and lessons were not learnt to continually identify and embed good practice. This meant people could not be assured of being supported in the most appropriate and safe way.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety or ensure sure there was continuity of care when people moved between different services. People and those who knew them well had been involved in assessments, however some support and risk plans had not been updated to reflect changes in people’s circumstances, preferences, or outcomes.

The provider did not work well with people to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, and avoidable harm. Concerns had not been shared quickly or appropriately, including where incidents reports suggested unlawful restraint may have occurred or where the actions of other tenant’s placed people at risk of harassment, abuse, or harm. This meant people were being supported by staff and a provider who were failing in their duties and responsibilities to report and protect them from avoidable harm. We informed the local safeguarding authority about the concerns found during our assessment.

The provider did not work well with people to understand and manage risks. Risks were not always managed by the least restrictive option. 1-1 staffing ratios enabled people to do the things that mattered to them; however, guidance was not always provided to keep people and staff safe. Staff had not been provided with guidance to support a person’s behaviour in the community, including when the person was violent towards them. Guidance was not in place to support a person to understand and manage risks about their personal safety. This included identified risks regarding road safety, exploitation, and exposure to substance misuse.

The provider did not detect and control potential risks in the care environment. Risks to people from other tenants and their visitors had not been robustly considered or managed. The inspection team observed a person smoking cannabis inside a supported living property. The person’s behaviour was argumentative and the person we were visiting went to their bedroom. There was a failure to identify risks associated with smoking inside the property, including the passive inhalation of cannabis and the behaviour of others whilst they were under the influence a class B drug.

The provider did not always ensure staff were knowledgeable and skilled. Staff received comprehensive training including training to support people with a learning disability and autistic people. However, staff did not always apply this learning to their practice. People’s care records and staff observed practice evidenced people did not always receive safe or personalised care. A consistent team of staff supported people. Staffing levels reflected the planned rota and there were enough staff to support people with their planned activities. Staff received regular supervision, and their performance was monitored through spot competency checks. Safe employment processes protected people from the recruitment of unsuitable staff.

The service assessed and managed the risk of infection. People were supported by staff who followed infection, prevention, and control (IPC) processes. Staff were knowledgeable about how to prevent the spread of infections and the need to use personal protective equipment. The service knew how to share infection concerns with appropriate agencies.

The provider made sure the management of medicines was safe. People received their medicines safely and in line with their preferences. There were systems in place that ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. People had regular medicine reviews with prescribers, to ensure their medicines were current and in line with the principles of STOMP (stopping over-medication of people with a learning disability or autistic people).