Elysium Care Partnerships Limited - 1a Upper Brighton Road

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 people were not always safe and protected from avoidable harm.

We identified the service was in breach of legal regulation in relation to safeguarding and safe care and treatment

This service scored 59 (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 ensure there was an effective learning culture which consistently embedded learning from incidents and promoted continuous improvement. Improvements were needed to ensure information about safety events was shared effectively with staff to support safe care and treatment.

Staff and managers described a culture where concerns, incidents and near misses were reported, reviewed and used as opportunities for learning. Staff told us they felt confident raising safeguarding concerns and escalating issues if they were not satisfied with the response. One staff member said, “Every time I have had a concern it has been addressed.” Another staff member told us they felt able to speak openly with managers and suggest improvements to the service.

The registered manager promoted a no-blame approach to learning and was able to provide examples of changes made following incidents. For example, following an incident where responsibility for supporting a person had not been clearly defined, the provider introduced clearer expectations around the handover of support responsibilities.

The provider had systems in place to support learning and improvement, including incident reporting systems, audits, management meetings, staff meetings and quality improvement plans. The positive behaviour support team regularly reviewed information relating to incidents, physical interventions and the use of as and when (PRN) medicines. Staff also had access to debriefs and wellbeing checks following incidents, which supported reflection and learning.

However, we found gaps in the provider's arrangements for sharing learning from incidents and safety events. Although incidents were recorded on an electronic system, key information was not consistently reflected within manual handover records. This meant staff may not always have access to the most up-to-date information about incidents, emerging risks or learning opportunities when providing care and support.

As a result, we could not be assured that lessons learned from safety events were always communicated effectively or in a timely way to reduce the risk of similar incidents occurring.

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.

The service supported people with complex health, behavioural and communication needs, and records showed involvement from external professionals. Staff worked with a range of healthcare professionals including epilepsy nurses, learning disability nurses, gastroenterology services, and dieticians. During the assessment, we observed a care worker supporting a dietician visit, and another supported a GP appointment. People had hospital passports, personal emergency evacuation plans and care records describing how to support appointments and transitions. One care record described in detail how to manage a GP appointment, including where a person preferred to wait.

The provider did not always ensure people were safeguarded from abuse, avoidable harm or restrictions that were not in line with best practice. Improvements were needed to ensure people's rights were consistently protected and promoted.

Staff understood their responsibilities to protect people from harm and were able to describe how they would recognise and report safeguarding concerns. Staff told us they would report concerns to managers and escalate concerns externally if required. One staff member said, “I do not have any concerns about reporting; I will raise it across services if I need to and make sure everyone is safe.”

The provider had safeguarding systems in place, including oversight from a group safeguarding lead, safeguarding trackers and audits which monitored safeguarding concerns. The safeguarding lead reviewed this information regularly and shared lessons learned across the service.

Relatives told us they felt people were generally safe. One relative said, “We feel they are safe and we are happy with the home.” Another said, “Overall, I feel they are in a safe environment.” This was particularly important as many people were unable to verbally communicate their experiences, meaning observations from relatives and staff helped provide assurance about people's safety and wellbeing.

However, we found the provider had implemented blanket restrictions which limited people's independence and freedom within their home. People were unable to independently access certain areas, including their bedrooms and the kitchen to obtain food and drinks. The provider had not demonstrated these restrictions were individually assessed, proportionate, or the least restrictive option available. This meant people were not always supported in a way that promoted their human rights, choice and independence.

The provider's systems had identified these restrictions, but the provider had not addressed this long-standing practice. As a result, some people were exposed to unnecessary restrictions which could negatively impact their autonomy and right to live as independently as possible.

The provider did not always work effectively with people and those important to them to understand and manage risks. Improvements were needed to ensure risk management was person-centred, up to date and developed in partnership with people and their representatives.

People had detailed risk assessments covering a range of areas, such as positive behaviour support, communication and eating and drinking. Staff were knowledgeable about the risks people faced and some relatives described positive joint working to reduce risks and avoid potential triggers. One relative told us, “We work together to avoid any triggers and keep them in their comfort zone as much as possible.”

However, we found the provider did not consistently involve people and their relatives in discussions about how risks should be managed in the least restrictive way. Some relatives told us they were not routinely involved in reviewing risks or agreeing strategies to support people safely while promoting their independence and choice.

We also found the provider used multiple care record systems, which resulted in duplication and some information not being updated. For example, one person's activity risk assessment referred to equipment that had been removed from the service. The risk assessment had not been reviewed to reflect the change or identify alternative opportunities to support the person's interests and wellbeing.

We could not be assured the provider was consistently working with people and their representatives to balance safety with choice, independence and positive risk-taking. The provider recognised improvements were needed and told us they planned to introduce a new approach to ensure people and their representatives were consistently involved in the assessment and management of risk; however, this had not been implemented.

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.

Systems were in place to comply with health and safety requirements such as water safety, and waste management. Gas and electrical safety certification were in date, and the provider had a ligature risk assessment in place. Staff received fire safety training and regular fire drills were undertaken to ensure staff and residents knew how to respond to a fire alarm.

However, fire safety risk records were inconsistent and the Control of Substances Hazardous to Health (COSHH) cupboard in the laundry room lacked signage. We found that information in people’s individual personal emergency evacuation plan (PEEP) differed from the information held in the fire risk assessment. We have asked the provider to review these risks and make the necessary changes.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Staffing levels were planned around people’s assessed needs, including 1-to-1 and 2-to-1 support in the community. The provider had a process to identify how many staff were needed, and planned rotas in advance. Staff were described as familiar with people, as bank staff were shared across local homes and there was no agency use. This helped provide continuity for people.

However, the service had several support worker vacancies, and recruitment was on-going. The provider confirmed vacancies were being covered by bank staff.Staff told us that last-minute absence could make shifts difficult. One staff member said, “Most of the time it is OK, but short-notice sickness could be a problem.” Another said “the duty rota has shifts which is always the correct amount and numbers, but sometimes last-minute absence can make it hard on workers. Sometimes managers can support us but not always.”

Relatives linked staffing pressures with cancelled or reduced activities. One relative told us, “Staffing can be a challenge, and I know that, but I don’t think [my relative] does enough in terms of activities”.

The provider had a process to monitor training; however, we identified shortfalls in staff completing training in relation to epilepsy, behaviour support and safe administration of medicines training. Although staff knew people well, gaps in training could affect how consistently staff understood and responded to risks. This was further evidence of a breach in relation to safe care and treatment.

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.

We observed clean and tidy communal areas, a clean kitchen, daily fridge temperature recording and food labelled and dated. The laundry was well organised and clean. Staff had daily allocated duties, and the manager described daily and weekly checks supported by a rolling rota of tasks.

The provider had an infection prevention and control contract and daily home management checks. Quality audits included room temperature checks, medicine fridge temperatures, repair log, and daily notes and handovers. These systems helped monitor cleanliness and infection risks.

There were some areas for improvement. The downstairs communal bathroom required redecoration or refurbishment to support effective cleaning routines. Records showed that food checks were not consistently completed.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines management and optimisation was safe, although some record keeping issues required improvement. MAR charts contained photo identification and allergy information. Stock counts were routinely completed; PRN medicines were in date and medicines audits were in place. Medicines were consistently audited, and the provider had medicines policies covering safe storage, control and administration.

The specialist lead for positive behaviour support considered medicines and any restraint used in relation to incidents of violence and aggression. This was important for people with learning disabilities and autistic people because it supported oversight of whether medicines or restraint were being used appropriately and not as a substitute for personalised support.

However, some medicine-related records were out of date or inconsistent. One medication plan referred to medicine no longer prescribed, and risk assessments were out of date in the medicine record but updated in other records. These issues meant the provider needed to strengthen medicines record keeping.