New Villas Office

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 remained Good.

Good: This meant people were supported and treated with dignity and respect.

The service was in breach of the legal regulation in relation to providing person centred care. We found the contents of care plans we reviewed were not regularly updated to reflect the risks to people and their current needs.

This service scored 63 (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.

Some incidents weren't recorded as part of the service's central recording system, so we weren't always assured that they were appropriately responded to and changes made to people's support as a result. Opportunities for learning and improvement were not always taken.

Incidents where people had communicated distress or frustration were recorded on antecedent, behaviour and consequences (ABC) charts. We saw these were generally completed with detailed information, however this was not always recorded objectively and debriefs after incidents with the person involved, the staff supporting them, and any other people were not always recorded for every incident. One person's care document showed 10 incidents, yet none of these had been recorded centrally. We saw that where external professionals had been involved in supporting staff to respond to, record, and debrief after incidents, these occurred and staff reported that they found them valuable. For example, we saw an incident had occurred in which a person sustained a facial wound during a period of increased agitation. Staff contacted an ambulance, this was recorded in the person's chart but there was no record elsewhere or evidence of a debrief or actions taken to prevent future occurrence. Complaints were not always recorded meaning outcomes and opportunities for improvement were not evident.

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

Most people had been supported by the service, and lived in their homes, for many years. Wereviewed care and support documentation for one person who had moved in and saw they had

a detailed transition plan, however other people had moved into their home in an emergencyand they did not have transition plans to ensure they were given time and consideration to

adjust to their new home.Additionally, the service did not always support people effectively to make changes that wereagreed in their best interests in a collaborative, joined-up way. One person had moved out oftheir home shortly before our inspection visit. We viewed their transitionplanand it was verybrief, detailing only the staff who would be supporting them without any other information tosupport the person to undergo this major life change. We received feedback from oneprofessional involved with the people who use the service, who told us that “[New Villas Office staff] have tried to disrupt the transition plan by cancelling visits and shadowing shifts from the new care provider.” Another person, who had moved into their home in an emergency, was living in accommodation managed by the provider that did not meet their needs as it did not provide them and their support staff with enough space to provide opportunities to de-escalate situations and calm down. Although another home had beenidentifiedthat was ready for the person to move in, concrete actions had not yet been taken by the provider to support the person to plan and undertake this transition. Notwithstanding the above, staff worked in partnership with health professionals and supported people to move safely through healthcare settings. When people had been admitted into hospital for treatment, staff supported the person to understand what was going on and provided hospital staff with the person’s Hospital Passport and information about their communication and any reasonable adjustments needed.

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, avoidableharmand neglect. The provider did not always share concerns quickly and appropriately.

The service had systems in place to safeguard people from the risk ofabuse,however these were not alwaysoperatedeffectively to ensure that people were protected from the risks of a closed culture. As each group of homes in which people lived was managed individually by a service manager over which the registered manager did not always have clear oversight, the service did not always have a cohesive, capable culture in which people’s rights were protected and promoted.All ofthe people who received support with personal care had their liberty restricted as they did not have the capacity to understand and make decisions about their safety themselves. These orders were authorised by the Court of Protection. However, we found that some people were significantly restricted in their movements and under constant surveillance from staff, and we were not assured that less restrictive alternatives had been explored and tested before these were agreed. For some people, the environment in which they lived provided further limitations as theywere not able toaccess outdoor space without staff support despite the outdoor space being a safe environment for them to spend time, and doing so assisted them to regulate their emotions and response to distress. The high turnover of service managers for some people’s support also meant that people and their representatives did not always know who was overseeing the support they received, and to whom they should report concerns. This also meant that a cohesive, capable culture in which people’s rights were promoted had not had the opportunity to grow and develop in the service. We saw that information on keeping safe was provided to people in easy read and pictorial formats, and keeping safe was discussed in some tenants’ meetings. Staff supported people to access independent advocates when this wasrequired.

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,supportiveand enabled people to do the things that mattered to them.

The provider had a system in place to assess,monitorand mitigate the risks relating to people’ssupport,however this did not always involve people and those who knew them well, and information was not always up to date. One personindicatedto us they felt safe with the staff who supported them in their home and in the community. Each person’s care and support recordscontaineda number ofrisk assessments that had been reviewedregularly,however these were not always up-to-date and did not always promote people to take positive risks to increase their independence,choiceand control. For example, one person had moved into their home in 2017, yet their risk assessment noted they could not yet be supported to learn the local bus routes as they were “new to the home.” Some people were supported by staff when they communicated distress or frustration, and external professionals had developed guidelines for staff to follow as part of holistic Positive Behaviour Support plans. These were comprehensive,objectiveand detailed and provided staff with de-escalation techniques before considering physical interventions to ensure people’s safety. However, other people’s risk assessments in this area were less detailed,weren’tup to date anddidn’tprovideappropriate guidance for staff. For example, one person’s risk assessment referred to “verbal outbursts and physical aggressions”,without any details about what the person was responding to and what staff could expect this to look like. The risk assessment referred staff to the person’s care and support plan for physical interventiontechniquesbut theseweren’tincluded in the care and support plan, leaving staff to respond withoutappropriate,thoroughand detailed guidance. People with specific medical conditions such as epilepsy and diabetes had thorough risk assessments with guidance for staff to manage these safely. These were developed and reviewed with input fromappropriate healthcareprofessionals.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure there were enough qualified,skilledand experienced staff, who received effective support,supervisionand development. They worked together well to provide safe care that met people’s individual needs.

Staff files we reviewed showed staff were appropriately appointed to roles and all necessary background checks were completed and documented.

Staff were trained to deliver their support roles by a combination of online and in person training. Training records were up to date and a clear effective process was in place to ensure mandatory training was complete. Relatives we spokewithfelt that staff were sufficiently skilled to deliver care to theirfamily members.

Staff had been trained in Positive Behaviour Support and an accredited physical intervention responsemethodology. Staff who used such techniques had annual face-to-face refresher training to ensure they remained skilled and competent at safely using these techniques.

Staff we spoke to told us they received training and updates to enable them to carry out their roles safely. Staffdemonstratedfamiliarity with safeguarding processes and how toidentifyconcerns.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Medicines were safely managed. There were systems for ordering,administeringand monitoring of medicines. Staff were trained anddeemedcompetent before they administered medicines. Medicines were safelysecuredand records were appropriately kept. We found that room and fridge temperatures were appropriatelymonitored.

People received their medicines as prescribed.  We looked at 5 people’s medicines and found no discrepancies in the recording of medicines administered. However, we found that a MAR chart had been handwritten without an authorised signature in place (in line with NICE guidance). Overall, this provided a level of assurance that clients received their medicines safely,consistentlyand as prescribed.

There were separate charts for people who had medicines such as patches, ointments and creams prescribed to them (such as pain relief patches) and there wasan appropriate medicinespolicy in place. Furthermore,unusedmedicinesweredisposed of regularly andappropriate recordsweremade.

During the inspection, we saw instances of where residents were prescribed PRN (asrequired) medicines and there were associated PRN protocols in place. This meant we had overall assurance that staff were able to administer these types of medicines effectively to residents, withinappropriate clinicalguidance.

There was a homely remedies procedure in place at the provider, withappropriate authorisationand oversight by the GP (although this was not currently in use).There were no residents who self-administered their medicines or had them covertly.

Although there were no reported medicines incidents recorded by the provider, we were assured that medicines related incidents would be investigated properly withappropriate actionplans and there would be processes in place to ensure staff learned from these incidents to prevent them occurring again.

The provider had a system tomonitorand audit people’s medicines on a regularbasisand we found that improvements had been madeas a result ofthis.For example, a monthly audit by the provider found that opening dates should be written on liquid medicines and on assessment, we found this to be the case.