Sense 12 Oakfield 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 requires improvement. At this assessment the rating has remained 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 people’s 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 had systems in place to facilitate a learning culture. However, lessons were not always learnt to continually identify and embed good practice.

There were systems in place that monitored incidents and accidents in the service and trends, and analysis of incidents took place. However, it was not always clear how learning had been implemented from these. The manager told us they were in the process of strengthening their systems so there would be a clear audit trail of lessons learnt, what actions had been considered and taken following a review of the incident or accident. This should ensure changes are made that improve care for others and we will review this as part of our next inspection. Staff spoken with understood their responsibility to raise concerns and report incidents and accidents.

There was a delay with some potential risks being identified and acted on for example we saw some risks in the garden and a delay with responding to concerns with fire doors not closing properly. Risks should be dealt with proactively before safety events happen.

The manager responded positively to any concerns raised and took action to mitigate any risks to people.

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.

There were systems in place to ensure people’s needs were appropriately assessed before they started using the service. These included a combination of face‑to‑face assessments and reviews of relevant records to support safe admissions.

People had hospital passports which included details about how best to communicate with the person, important contacts, medicines and their physical health and emotional wellbeing needs.

Staff knew people well and understood their needs and wishes.

Staff had contact with professionals from outside of the home who supported people with their health, medical needs and behavioural support. This included consultants, GP’s and learning disability specialists. We received positive feedback regarding how the service worked with professionals.

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.

The provider shared concerns appropriately by following the correct process and ensuring these were reported to relevant agencies. Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The provider had procedures in place to protect people from abuse. Staff told us, and training records confirmed, they received training on safeguarding adults from abuse. They felt confident any concerns they raised would be managed appropriately. A staff member told us, “If I had any concerns I would speak to one of the managers and they would report to the local authority and safeguarding team and the CQC.” Another staff member told us, “Managers make it very clear what we should do if we have any concerns about people’s care. I would share my concerns with the manager.”

The provider was aware of their responsibility to work with the local authority where people had a court of protection in place and had oversight of this.

The provider did not work well with people to understand and manage risks.

At our last inspection we found the systems in place to mitigate and monitor risks to people were ineffective and had the potential to put people at risk of harm. Although some improvements had been made, we again found some risks were not adequately managed and this increased the risk of harm to people.

Care plans and risk assessment did not consistently provide adequate guidance for staff to follow when managing risks. For example, we found a falls risk assessment had not been completed for a person identified as at a high risk of falls. There was limited guidance for a person who needed support to safely access the bathroom, and a moving and handling assessment had not been completed. Staff shared with us during the assessment their concerns about the person’s safety. A person was at risk of choking due to problems swallowing. There was inconsistency in information about how to support the person safely. A screening tool for assessing risks had been completed but had not identified the error. There was inaccurate information regarding supporting a person with their epilepsy medicines. Although reviews on care plans had been completed, the inconsistencies and errors had not been identified.

Environmental risks were not always identified or addressed in a timely way. During the inspection we observed concerns that indicated potential risks to people were not managed safely or proactively. This included potential risks in the garden that people accessed.

The manager responded positively to all the issues raised and took action where they could and gave reassurance about people’s safety and wellbeing.

The provider did not always detect and control potential risks in the care environment.

People freely accessed the grounds of the supported living service. However, we saw a number of potential health and safety issues including a broken chair and other items of broken furniture; a trampoline with damaged safety pad which exposed the cushioned foam interior; an inflatable paddling pool filled with debris and stagnant water; and several discarded cardboard boxes piled against the side of the premises. In addition, the provider had failed to escalate concerns staff had shared for a number of months regarding fire doors not closing properly.

The provider was providing care and support to people in their own homes. There was a process in place for reporting issues to the landlord and the manager told us requests were responded to promptly. Staff had received training in how to use equipment safely.

The provider took prompt action on all the issues we raised, and assurance was given about lessons learnt from the inspection.

The 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.

The provider ensured staffing levels were planned to reflect the needs of people and the staffing levels agreed by the funding authority. The service did use some agency staff whilst recruitment was taking place, but regular staff were used where possible to maintain consistency.

Staff received a mixture of e-learning and in-person practical and theoretical mandatory training which were relevant to their role and was routinely refreshed. In addition, staff received specific training to ensure they could meet the needs of the people they supported. This included training in relation to specific health care needs including epilepsy awareness.

Staff had opportunities to reflect on their working practices and to identify any further training, learning or support they might need. Staff received regular supervision, appraisal and competency checks. Staff told us they were generally satisfied with the arrangements in place for staff training but sometimes it was difficult to complete online training when working on shift. The provider assured us all staff would be supported with additional support and time to complete required training. They also told us where any gaps in staffs’ knowledge and skills were identified steps would be taken to address the shortfalls.

The provider operated safe recruitment practices and only suitable staff were employed to work for this provider. Recruitment processes included appropriate checks, induction and probation.

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.

People were protected from the risk of cross infection. We saw shared communal areas were clean and people were supported to keep their own living space clean, with support from staff. Staff told us they had received training and there was enough Personal Protective Equipment (PPE) available for them to use. There were processes in place to ensure concerns with Infection Prevention and Control (IPC) were identified so that appropriate action could be taken.

The provider did not ensure people’s emergency medicines were safely managed.

We found some inconsistencies for 1 person who was prescribed rescue medicine for the management of Epilepsy. The instruction on an emergency protocol and the person’s care plan regarding the time frame for staff administering the emergency medicines were different. This meant there was a risk of a short delay in the person receiving the prescribed medicine. The manager took immediate action and ensured all documents were reviewed and updated, and all staff were briefed on the incident. There had been no incidents where the person had been put at risk with a delay in treatment.

Medicines were stored safely and checks were completed to ensure stocks were accurate. Staff administering medicines had received training to ensure they were safe to administer these to people and competency assessments had been completed to ensure staff had the skills to administer medicines safely. The manager carried out audits of medicines records to monitor medicines support and identify any discrepancies. However, this failed to identify the concern we found.