GFI@112

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 newly registered 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 people’s safe care and treatment and governance at the service.

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 had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and reported safety events. Management teams investigated events to identify actions and lessons learnt.

Staff reported safety events, and records showed these were logged appropriately. Staff told us they received debriefs after incidents, during which managers discussed lessons learned and how to prevent similar events reoccurring, although records did not clearly reflect these discussions. A staff member told us, “I feel incidents are investigated promptly and fairly to ensure everyone who is involved is heard and supported.”

The registered manager explained safety events and learning were used to review people’s care and inform policy changes.

One staff member described an incident where a person displayed behaviour that communicated distress. Following this, the team introduced strategies to identify early triggers and review seating arrangements to future reduce risk in future. A person’s relative told us, “I feel [person] is safe.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

The provider did not always manage or monitor people’s safety when moving between different services. People’s care, health and clinical outcomes were not recorded when transferring between services on a regular basis. Hospital passports did not contain any detail relating to people’s communication needs, their medical conditions, or what medicines they took.

This meant people were placed at increased risk of unsafe or poorly coordinated transfers of care.

Where the provider completed delegated healthcare tasks, there was no guidance for staff as to who to contact if any safety events occurred. The provider did not have clear oversight of who held responsibility for delegated healthcare tasks and did not take proactive steps to clarify this with healthcare partners. We gave feedback to the provider who acted to remedy this.

The provider shared examples of using social stories to support people who were new to the service and to help ease their transition. Staff received bespoke training to support individuals with their health needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had received safeguarding training for adults and children and understood how to protect people’s rights. The provider reported safeguarding concerns to the local authority and worked in partnership with them to investigate and address concerns. The provider had an in-date safeguarding policy that staff were able to access.

Staff had a good understanding of how to report safeguarding concerns. One staff member told us, “I would make a factual record of what I observed, including dates, times, and exactly what was said or seen. If the concern involved a manager or if I felt the concern was not being addressed appropriately, I would follow the whistleblowing procedure and escalate it further.” This meant that people were better protected from the risk of abuse.

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.

The provider did not always adequately assess or mitigate risks associated with people’s care. People’s risk assessments did not always identify, or address risks linked to their health conditions. For example, 1 person’s care records identified they were at risk of choking, however, there was no guidance for staff as to how they should manage a choking event around the person’s specific care needs. They also did not identify risks associated with the person’s medicines. This meant people were at increased risk of harm.

However, the provider demonstrated a positive approach to supporting people to take informed, positive risks. For example, 1 person was supported to engage in activities that had been identified as risky for them, with tailored measures put in place to ensure these were carried out safely. Risks associated with behaviour that communicated a need or distress were appropriately assessed, and clear guidance was in place to help staff respond in ways that protected both the person and others from harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were supported to manage potential risks to them during their care in the community, at activities or in their home. The provider ensured that people had their relevant equipment available to them and in good working order.

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.

Staff had received some appropriate training for their roles; however, training records showed that not all staff were up to date with essential training, including moving and handling, and staff had not been offered or completed required learning disability and autism training.We gave feedback to the provider, who took steps to book training for staff.

Recruitment files did not always contain full employment or educational histories, nor written explanations for gaps in employment. As a result, the provider could not always be assured that recruitment processes were consistently safe, fair and robust. Following our feedback, the provider took steps to strengthen recruitment practices.

However, references were sought and Disclosure and Barring Service (DBS) checks were completed before staff commenced employment.

Staff were required to complete shadow shifts before working independently. One staff member told us, “I was introduced to the people we support, their care plans, risk assessments, communication needs, preferences and routines. I had opportunities to shadow experienced colleagues and observe how support was delivered before working independently.” This meant staff were able to get to know people’s needs before they started working with them independently.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

A person and their relative told us that staff did not wear Personal Protective Equipment (PPE) when providing personal care and support with health needs. Records did not document whether PPE had been used, and the registered manager confirmed that no observations were carried out to check staff compliance with PPE requirements. This meant people were at increased risk of infection. However, a person’s relative told us they had observed staff practising appropriate hand hygiene measures.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider gave flexible support at different times of day, so as a result, care was transferred from other providers. There was no shared protocol in place between providers of care. Staff did not always record whether a person’s medicines were administered as prescribed, or handover from other care providers. On some days, there was no recorded evidence that medicines had been given at all by the provider, placing people at increased risk of missed doses or receiving too much medicine. Although staff recorded medicine stock levels, they did not do this consistently, or escalate concerns when stocks ran out. In addition, Medicines Administration Records (MAR) charts and care records did not include all medicines that should have been administered during care calls. For example, 1 person’s medicine to support their nutritional needs was not recorded as a required medicine. We did not identify any harm to people in response to our feedback, the provider took steps to improve their practise around medicines management.