Sturbridge

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.

This is the first assessment for this service. This key question has been rated 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 safe care and treatment. 

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.

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.

Staff did not raise any concerns with us about the learning culture within the service, and relatives and staff told us they felt able to raise safety concerns and that these would be addressed. The management team told us about processes in place to learn from incidents, should they arise, including debrief sessions involving the in-house counsellor if needed. There had not been any significant safety events during the assessment period. However, opportunities to identify and embed good practice had been missed.

A recent audit had identified that risks were not always being systematically assessed, but there was no evidence that action had been taken in response to these findings. No action plan had been developed, and risk assessments had not been amended or updated. In addition, not all concerns identified during our assessment had been recognised in the audit, meaning the provider had missed opportunities to learn and improve.

The service had also been without a registered manager for some time, and this had contributed to a weakened learning culture. The lack of consistent leadership and oversight meant the provider had not always ensured that learning was captured, shared or acted upon in a timely and effective way.

As a result, although staff and relatives felt able to speak up, the provider did not demonstrate a proactive or robust approach to learning and continuous improvement.

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.

People experienced safe and well-managed pathways of care. Relatives told us the referral process worked well and was handled efficiently by the service. One relative said, “The referral process was very good. The manager came out and met with [person], myself and other relative.” Another relative said the manager who carried out the initial assessment had taken time to research and understand the person’s condition before care started. This meant assessments were informed, person-centred and based on a good understanding of people’s needs.

Staff were introduced to people in advance, enabling them to build confidence and rapport before support began. Relatives explained that they had experienced poor transitions and inconsistent approaches with previous services, but they described feeling reassured and put at ease by this provider. They told us the service’s approach helped reduce anxiety and made the transition into care smoother and more positive.

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

Staff had completed safeguarding training and were able to explain when and how they would escalate concerns. Relatives told us that people felt safe with the staff who supported them, and we saw no evidence to suggest that people were at risk of abuse or neglect. One relative said, “I haven’t had to raise any concerns for [person’s] safety.” Although no statutory safeguarding notifications had been submitted to the Commission, there was also no evidence that any safeguarding incidents had taken place during the assessment period.

The provider did not demonstrate a clear understanding of its responsibilities under the Mental Capacity Act (MCA). Some people using the service had limited choice and control over aspects of their daily lives, and the provider had not evidenced that decisions were made in line with the principles of the MCA. This created a risk that people’s rights may not always be fully promoted or protected.

As a result, although people felt safe and staff knew how to report safeguarding concerns, shortfalls remained in the provider’s understanding and application of the MCA and ensuring people’s rights were protected.

The provider did not assess or manage risks to people’s health, safety and wellbeing. Risks were not identified, monitored or reviewed, and people were exposed to avoidable harm.

Not all individual risks had been assessed, and this meant staff did not always have the information they needed to provide safe, person-centred support.

One person chose to spend a significant amount of time on the floor at home. However, there was no moving and handling risk assessment in place to guide staff on how to support them safely. It appeared that, until a staff member raised concerns in December, two staff had been lifting the person from the floor manually without appropriate equipment or guidance. An inflatable chair was later put in place, but the person’s relative told us this was only used on occasion. Parents continued to lift the person from the floor to the sofa, with staff then assisting them to stand from there. The lack of a risk assessment and unclear guidance meant risks around safe handling were not fully understood or managed putting the person at staff at risk of injury.

The same person also had a condition causing sudden involuntary muscle jerks. This was not documented in their care plan, and no associated risk assessments were in place. Staff therefore lacked essential information about how to anticipate, monitor or manage this known health-related risk.

Another person was taking anticoagulant medication. Despite the increased risk of serious harm from injury due to anticoagulant use, there were no risk assessments that considered this or set out measures to reduce the likelihood of harm. Where risks had been identified, these were not supported by a risk management plan.

A recent audit carried out by the provider had identified that risks were not always being systematically assessed. However, there was no evidence that any action had been taken in response to these findings. The provider had not developed an action plan to address the shortfalls, nor had they updated or amended individual risk assessments following the audit. This meant that known gaps in risk management processes remained unaddressed, and people continued to be exposed to avoidable risks.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

There were no environmental risk assessments in place, meaning the provider did not have a clear understanding of hazards within people’s homes or how these could affect the safety of people or staff.

Where people required assistance to transfer, there appeared to be no suitable equipment available to support this safely. This meant staff did not always have the resources they needed to provide safe care. In situations where people had been identified as being at risk of falls, the environment had not been assessed to determine whether any adaptations or control measures were required to help manage these risks.

It also appeared that the provider had not considered whether staff themselves were safe in people’s home environments. The absence of environmental assessments meant there was no assurance that conditions were suitable for staff to deliver care safely and without undue risk.

As a result, the provider did not have effective systems in place to ensure that people’s environments were safe, appropriately equipped, or assessed in line with identified risks.

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

Appropriate preemployment checks had been completed before staff began supporting people. This included Disclosure and Barring Service (DBS) checks, obtaining two references, and ensuring any gaps in employment were fully explored. These checks helped ensure staff were suitable and safe to work with people.

Staff received appropriate training relevant to their roles, and people’s relatives told us they felt staff were knowledgeable and competent. They told us they were confident in the staff’s ability to provide safe and effective care. One staff member said, “I have received training in areas such as learning disabilities, autism, safeguarding and medication. I feel the training is helpful and supports me in my role.”

We also saw that staff were reliable and arrived promptly for scheduled visits. This supported people to receive consistent care that met their needs.

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.

Relatives told us that staff always used appropriate personal protective equipment (PPE) during care tasks, which helped ensure people were protected from the risk of infection. Care plans contained clear reminders for staff to use PPE correctly and to dispose of it in line with good infection prevention and control practices.

There was also evidence that the provider carried out hand hygiene competency checks. This helped ensure staff followed safe handwashing techniques, further reducing the risk of infection spreading.

The provider did not always make sure that medicines and treatments were safe or that staff had the information they needed to support people effectively. Although people or their relatives generally managed medicines themselves, these were not always clearly documented in people’s care plans. This meant staff did not always have the necessary information to identify when someone might be experiencing side effects, or to share accurate details with healthcare professionals when needed.

One person was prescribed an anticoagulant medicine, but there was no risk assessment in place to reflect the increased risk of harm from injury associated with anticoagulant use. This meant staff did not have clear guidance on how to monitor or respond to potential risks. The same person also required the occasional use of an inhaler, but the PRN protocol did not contain enough information to guide staff on when this should be administered. Their relative told us the person was able to use the inhaler independently, but the lack of clear instructions created a risk of inconsistent practice.

This person was also diabetic, yet there was no care plan or risk assessment in place to support staff in recognising or responding to diabetes related risks. Although their relatives managed the diabetes medicine, we saw evidence that training was being arranged for staff to administer this when supporting the person in the future. However, without a current care plan or risk assessment, staff did not have the essential information needed to manage this safely.

Overall, gaps in documentation and the absence of risk assessments meant medicines were not always managed in a safe and consistent way.