Archived: 58 Acton Lane

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• 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.

Based on the findings of this assessment the rating for this key question has changed from good to requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. This was because we found concerns with medicines optimisation, staffing and managing risks. These failures had placed people at risk of harm under 2 breaches of Regulations. Regulation 12 (Safe Care and Treatment) and Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed the complaints log, which reflected the service had not received any complaints in the last year. Team meeting minutes indicated that feedback and areas of improvements were discussed, however staff did not always listen to concerns about safety. Lessons were not always learnt to continually identify and embed good practice. For example, although the fridge and freezer were adequately stocked, items such as milk, ketchup and fruit containers were not labelled with the date they had been opened. This is essential for food safety and expiration management, as these items had recommended use-by dates after they are opened. Staff we spoke with told us this had already been highlighted at an external audit. This indicated a lack of action taken in response to feedback provided from external audits.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. The care records for 2 people were not present at the service on the day of assessment. Staff informed us the interim manager had taken these records to another service to review and update. Staff told us they did not have access to another copy of these care records. The records contained sensitive and essential information regarding people’s care, medical history, individual needs and emergency contact details. Without access to this information, there was a risk that staff may not fully understand, respond to or meet the specific care needs of the people they supported. This raised concerns with regards to safe and effective care, data protection and accessibility, particularly in the event of a medical emergency where people may need to move between services. Due to the risks to the people who reside in the service, this is a breach of regulation 12 safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a clear safeguarding policies and procedures which were kept up to date, and easy for staff to access. According to training records, all staff had completed their training in safeguarding, however staff did not always understand what being safe meant and how to achieve that. They were not fully aware of external reporting processes and procedures. Commissioners informed us the service did not always share concerns quickly and appropriately.

The service had a staff team who were familiar with people’s daily routines, preferences, and risks. Staff were able to provide examples of when they had identified situations which placed people at risk and how they responded to manage those risks. The service had ABC behaviour chartsin place for all people living at the service and we reviewed 2 Positive Behavioural Support (PBS) plans. These demonstrated the service worked with partners and people to understand and manage risks.

We reviewed the service’s incident reporting policy and emergency protocol. However, staff showed us the lone working policy. It was unclear on the day of assessment if the service had these protocols in place. An emergency protocol is necessary for the safety and wellbeing of both people who lived at the service and staff in ensuring a coordinated and effective response during emergency situations and incidents. According to the duty rota, the interim manager was on-call day and night, 7 days a week. Arrangements for cover in the event of the absence of the interim manager were unclear. We requested immediate assurances to ensure peoples safety. The interim manager provided the service’s up-to-date escalation process reporting procedures for emergencies, incidents and concerns and ensured this was accessible to all staff and will be discussed in team meetings and individual supervision to refresh staff on this policy and process. The policy stated incidents must be reported to senior support staff or the interim manager.

The service had up-to-date personal emergency evacuation plans (PEEPs) in place for all people living at the service. The environment had adaptations and reasonable adjustments in place to meet people’s individual needs. However, the service did not always detect and control potential risks in the care environment. For example, windows in people’s bedrooms opened very widely, and there were no window restrictors in place to ensure people’s safety. This posed a potential risk relating to falls and building security and impacted the safety of people living at the service. We spoke with building maintenance staff, who informed us window restrictors would be implemented immediately.

Relatives told us, “The staff are caring and they put clients first,” and that the staff team “are very supportive.” Relatives told us people felt safe in the presence of staff and the other people living at the service.

The service had been without a registered manager since 2021. At the time of our assessment, an interim manager was in post, however they were not registered with the Care Quality Commission (CQC). The service had employed an external company to support in the recruitment of a new registered manager. Recruitment remained ongoing at the time of our assessment.

The service had 4 permanent employees, consisting of 1 senior support worker and 3 support workers. We reviewed the duty rota for April 2025 to May 2025. On the day of our assessment, the service was rostered to have 1 senior support worker and 2 support workers on shift in addition to the interim manager. However, the interim manager and 1 support worker were absent due to sickness, leaving 2 staff members to cover the daily running of the service. No alternate cover had been arranged. Staff told us the service did not use agency staff. According to the latest ‘Service Action and Improvement Plan’, staff burnout had been identified as a current challenge. The service was rostered to have 1 waking staff member at night. Care records reviewed indicated some people required 1-1 support to access the community and 1-1 support at night. It was unclear how these needs were met during staffing shortages, and if 1-1 hours were being implemented according to people’s individual care needs. Due to the risks to the people who reside in the service, this is a breach of regulation 18 staffing under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service’s staff turnover and sickness rates were low. The service was recruiting for 2 support workers and were in the process of employing a new staff member subject to mandatory checks. We reviewed 2 staff recruitment files and saw that appropriate processes and checks were in place. The service conducted enhanced disclosure and barring service (DBS) checks, which provided information held on the Police National Computer. This information helped the service make safer recruitment decisions.

The service had mandatory training, staff handbook and induction checklists in place for all new starters. The interim manager and senior support worker were accountable for ensuring the pathway is completed by new staff members and signed off. Training records showed that staff received ongoing training that was appropriate for their role. Training records for the service indicated 100% staff training compliance in mandatory areas including infection control, first aid, epilepsy awareness, health safety and dignity in care. However, records indicated 50% staff training compliance in learning disability awareness and PBS.

Supervision records showed all staff had regular supervision meetings with the interim manager to support them in their role and to identify any further training or learning they might need. The service also undertook annual staff appraisals.

The service assessed and managed the risk of infection. Hand hygiene information was displayed in appropriate areas of the service, ensuring that all staff, people who lived at the service and visitors had access to and guidance on good hand hygiene practices. The service appeared generally clean. Cleaning staff attended the service twice a week and were present on the day of our assessment.

The service did not always make sure that medicines and treatments were managed safely. For example, 1 person did not have a PRN protocol in place for a medicine that was considered as hypnotics, sedatives and anxiolytics (benzodiazepines). We found gaps in medicine administration records for medicine weekly checks for 1 person. The service did not have robust medicine audits and checks in place. Staff we spoke with told us medication audits were completed by the interim manager on a weekly basis; however, records were not in place to confirm this. Furthermore, prescribed creams were stored in an unlocked kitchen cupboard and were not organised in in line with best practice. There were no dates marked on the creams to state when they had been opened. The labels on the creams were difficult to read due to fading, which made it difficult to determine which cream belonged to which person. There were also empty prescribed creams which needed to be discarded. Staff we spoke with did not appear to understand the importance of recording the dates creams had been opened. This placed people at risk of receiving creams which were unsafe to use. We asked the service to review the suitability of where creams were stored due to the changes in temperature in the kitchen area. Due to the associated risks to the people who reside at the service, this is a breach of regulation 12 safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.