The Coach 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 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 regulation in relation to people’s safe care and treatment and staffing.

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 listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The manager had shared their concerns on safety with the provider however, they did not have a working action plan in place as to how and when concerns would be addressed by the provider. The manager had implemented regular staff meetings with staff to discuss learning. However, they had not used these meetings to discuss learning from incidents or a recent safeguarding concern.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Before people moved to the service their needs were identified and the support they required was discussed with them and their relatives or advocates. Staff worked closely with other healthcare professionals such as speech and language therapist and GPs to ensure their needs were met safely and reviewed regularly.

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 concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, and discrimination. The manager had not always recognised the seriousness of environmental safety and had not raised a safeguarding concern in relation to this. Staff told us they knew how to raise concerns one member of staff said, “I would make sure the environment is safe and the people we are supporting are safe. I would report to the manager if someone was at the risk of abuse.” We saw safeguarding was an agenda item to discuss in team meetings and during supervision. A recent safeguarding concern had been investigated by the local authority and during this time the manager had put measures in place to safeguard people.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. There were not always robust risk assessments in place to manage risks to people safely. We found where people were receiving care for a tracheostomy there were no protocols in place for what to do if an emergency replacement was required. This lack of guidance placed people at risk of staff not knowing how to react in an emergency. A tracheostomy is a surgical procedure that creates an opening or stoma in the front of the neck into the windpipe (trachea). A tube called a tracheostomy tube, is inserted into the opening to help with breathing. This tube allows air to bypass the nose and mouth, ensuring oxygen reaches the lungs. Emergency tracheostomy kits may contain equipment staff could need quick access to such as, replacement tracheal tubes, tracheal dilators, swabs, lubricating gel, scissors and surgical gloves. Emergency tracheostomy kits did not have an inventory of what they should contain, and no audits were completed to ensure what was in the kits were in date and was the correct equipment needed. This placed people at risk of not having the care they needed in an emergency.

This demonstrated a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safe care and treatment.

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.We found the provider had been slow in reacting to risks in the environment. This included not ensuring window restrictors were in place when these had been highlighted as missing. There had been a delay in changing an external fire door and ensuring this was alarmed appropriately. Both of these placed people at risk of falling from height. The manager had not put sufficient mitigation in place to keep people safe and had been over reliant on raising the issue with the provider to address and had not put mitigation in place in the interim. Where a locked had been broken on a store cupboard the manager had not made any attempt to review what was held in the cupboard and if this needed removing for safety.

This demonstrated a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safe care and treatment.

Following the inspection, the manager was able to offer some assurance that they had taken steps to mitigate these risks. We noted some redecoration had been completed at the service and that some recommendations from the last fire inspection had been implemented.

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 manager had failed to ensure agency staff working at the service had up to date training. We found no agency profiles available for 2 staff and for 1 member of staff their profile showed their training as being completed in 2022 with no evidence of updates. The manager had a training matrix in place however, they had not implemented or developed an action of plan of how they would address out of date or not completed training with staff. We found 5 staff had not completed practical training for moving and handling, tracheostomy care and suctioning. We could not be assured there would always be staff available with the correct skills to provide support. Not all staff had received supervision consistently and qualified nurses had not had their competency assessed to administer medicines.

This demonstrated a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staffing.

Following the inspection the manager assured us they were arranging further training and had updated the qualified nurses supervision and medicine competencies.

Staff were recruited safely to work at the service this included obtaining references and Disclosure and Barring (DBS) checks. We would recommend the provider verifies references received to ensure they came from a reliable source.

Relatives we spoke with were complimentary of the staff and support they gave their loved ones. A relative said, “I am amazed at how good staff are, can not fault them.” Another relative said, “We are very happy with the care.”

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 manager had recently held a workshop with staff to refresh their knowledge on infection prevention and control (IPC). We saw personal protection equipment (PPE) was available for staff to use when needed. There was an audit completed monthly on IPC however, there was no action plan in place for how issues would be addressed or timeframes for these to be completed.

We could not be assured that medicines were being managed safely. The provider had implemented a new electronic medication administration recording system. However, the manager had not implemented effective audits to run alongside this system to ensure people were receiving their medicines as prescribed. We found stock numbers did not match what was being held at the service. The manager said they would address this with the pharmacy provider and complete a full stock check.

As previously mentioned, we found staff who were administering medicines had not routinely had their competency checked to ensure they were doing this safely. Following the inspection the manager informed us they had now updated staff competency.