Magic House

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 people could be harmed. Under this key question, we found breaches of regulations in relation to safe care and treatment of people; safeguarding people from abuse, avoidable harm and neglect; and staffing.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were supported to raise concerns and had a say in their care. Staff worked in collaboration with people and their relatives to find ways to improve people’s experiences. This personalised approach helped staff find better ways to support people. One relative told us, “It’s been on and off, definitely better, got a new manager now who is doing their best to improve things.”

Staff contributed to the development of people’s care and support plans. They knew how to report accidents and incidents, and had regular opportunities to discuss concerns with their managers. Staff told us they attended regular team meetings to discuss general issues and any concerns they had regarding people’s care, and learnt from past incidents.

Feedback from local authorities and commissioning teams were mixed. Some of these partners reported positive changes in certain parts of the service while others told us Magic Life were unable to sustain improvements. An external professional spoke about one of the supported living schemes and described a culture of complacency as a result of the gap between local and senior management.

While the service engaged people, their relatives and staff to discuss issues, learn from mistakes and make improvements, the overall process of learning to inform service improvements was not robust enough. Where recorded, accident and incident forms were comprehensive and provided a clear picture of what potentially went wrong, which could be used to make improvements. However, not all accidents and incidents were recorded effectively. For example, when 2 people had seizures, these were not recorded as incidents, which meant there was a lack of management oversight to ensure these incidents were appropriately analysed. In some supported living schemes, there were either no records of accidents and incidents or records were missing for extended periods. Although accidents and incidents were discussed locally within some schemes for learning purposes, we could not confirm that trends and patterns were being effectively monitored and analysed across the service to ensure that learning led to improvements. For example, we found a lack of analysis following an incident where a person became aggressive when they went out with staff. The completed documentation did not provide sufficient assurance around any measures adopted to support this individual and minimise this type of incident or the impact of it.

People and relatives spoke positively about their experiences when they first started using the service. They described the transition from previous placements to Magic Life as “a good induction” and “collaborative”. A relative told us, “The transition went so smoothly, had transition days for 4 to 5 weeks, so [person] was already familiar before they moved in.”

The registered manager explained people’s needs, including suitability and compatibility of placement, were assessed before they started using the service. They told us, “Placing authorities, people and families come and visit.” Transition visits, which the durations varied according to people’s individual needs, were arranged so that people could get to know the staff and become familiar with the service. A local manager told us they were involved in the transition process. They said, “They need my opinion to know whether our service can support the person."

Local authorities were not always informed when people from outer boroughs started using the service. This could potentially impact the smooth partnership working between the service and local teams, such as learning disability teams, which could potentially impact the care people received, especially people with complex needs.

To ensure continuity of care when people moved between services, the service carried out a pre-admission assessment of people’s needs, arranged the necessary training for staff, developed a comprehensive transition plan and gathered the views of people, their relatives and commissioning teams. However, we found the pre-admission assessments for 2 people did not gather sufficient information, including key information about them and their specific needs. For 1 case in particular, it was not clear how the service concluded they would be able to meet the person’s needs safely due to the limited information they gathered in the pre-admission assessment process. A noncomprehensive pre-admission assessment could result in the service struggling to meet people’s needs and a rise in incidents.

Feedback from people and their relatives indicated an inconsistent approach from the service to ensure people were protected from harm and/or improper care. Most people and their relatives told us they felt safe using the service. Quotes included, “I feel safe here”, “100% safe” and “[Person] is very well looked after.” However, the experience for some people and their relatives around safety at the service was concerning. For example, a relative said they “did not feel [person] was in safe hands.”

Staff knew what abuse was and its signs. They were aware of their responsibility to report concerns and knew how to do so. If they suspected abuse, a staff member told us they would “immediately report to management, write incident form and contact safeguarding team”.

Interactions between people and staff were respectful. Communal areas were monitored by close circuit television (CCTV) and there were appropriate safeguards in place to ensure the use of CCTV was in line with national standards. This promoted a safe environment for both people and staff, while upholding people’s human rights.

Managers investigated safeguarding concerns and implemented protection plans for people in response to these concerns. However, in parts of the service, people were exposed to risks of harm and/or improper care recurrently due to ineffective preventative systems to safeguard them. For example, there had been a number of medicines errors/incidents in the 12 months leading to the inspection, while an internal audit found staff competency assessments for managing and/or administering medicines were not up to date. People’s risk assessments were not always fit for purpose or adhered to. Support around sexual safety and empowerment for people who had sexual vulnerabilities and/or impulses was not always clearly documented; the registered manager told us following the assessment that they were working with external professionals to improve the support provided to people in this area. These issues showed processes to safeguard people from harm and/or improper care were not robust and were potential contributing factors to many wide-ranging incidents across the different supported living schemes. We also found a person’s room to be in a state of disrepair, which showed the service did not take the appropriate responsive actions to ensure maintenance issues were escalated effectively. This was addressed promptly after the inspection visit.

People’s experiences of safety were mixed and based on their individual circumstances, such as, physical and emotional needs, the particular supported living scheme they lived at, and the quality, consistency and competency of their staff teams. Some people were comfortable with the care and support they received and had no concerns about safety. Other people were exposed to risk of harm due to shortfalls in how the service assessed risks. A relative told us, due to a language barrier staff were not able to positively engage with a person to provide support that was based on verbal strategies to reduce risks.

Staff we spoke with demonstrated knowledge of people’s needs and they spoke confidently about how they supported people in their daily activities. One staff member explained the signs and triggers displayed by a person when they became agitated and the techniques they used to help them feel calmer, as well as the importance of following the person’s preferred routines. Staff also told us they involved, people, relatives and external agencies when developing risk assessments for people.

People received appropriate staff supervision to be able to do the things they enjoyed. We observed staff giving 1 person space and privacy, as per their risk assessments, when their mood escalated. However, we saw one person trying to consume a snack in a way that did not reflect the guidelines from their risk assessments. Due to their swallowing difficulties, the person was at risk of choking. We raised this with the managers on the day of the inspection visit.

Despite the positive feedback we received from some people, relatives and staff regarding the safety of people using the service, processes for assessing risks to people’s health, care and safety were not always adequate. We found risks or hazards were not always clearly defined and/or assessed; care plans and risk assessments contained conflicting information; measures to reduce risks were not always clearly explained and risk assessments were not always followed. For example, staff offered 1 person foods that should be avoided due to their swallowing difficulties, according to their care plan. The person also suffered from hypothyroidism and hypertension but their risk assessments did not provide information for staff on any arrangements for regular blood tests and blood pressure checks to ensure these conditions were monitored safely and effectively. For another person who exhibited aggression when agitated, their risk assessments did not provide instructions for staff on how to manage this risk or react when the person displayed this behaviour. There was no risk assessment in place for 1 person who was at risk of choking. For another person who was diagnosed with epilepsy, instructions for staff on the actions to take if the person had a seizure differed from their care plan to their risk assessments. Conflicting information could result in staff not taking the right action at the right time, which could affect the safety and wellbeing of the person. These concerns showed people’s risks were not always properly assessed, placing them at risk of harm. However, some people had comprehensive and person-centred risk assessments that provided clear guidance to staff. Positive Behaviour Support plans were also in place for some people with a learning disability, offering detailed strategies for safe support. The service maintained a clear policy on restrictive practices.

People and their relatives felt they received appropriate support from the staff and managers regarding the safety and maintenance of their accommodation. One person told us, “I feel safe here, I stay in my room mostly. I chose to have my door closed.”

The registered manager told us they assessed people’s physical environment before they moved in to ensure their accommodation was safe and suitable for their individual needs.

Communal areas, and some of the rooms and flats we observed were tidy and free from any visible hazards.

There was a process to report maintenance and safety issues which staff were familiar with. Managers carried out regular health and safety checks in the form of audits and spot checks. People had Personal Emergency Evacuation Protocols in place which provided key information on how to support them to evacuate safely in the event of a fire.

Feedback from people and relatives indicated a high staff turnover in some supported living schemes resulting in inconsistent staff teams. This inconsistency increased the anxiety levels for some people. A relative told us the high staff turnover was a problem for [person] who has complex needs and became easily agitated. Other comments from relatives included, “High staff turnover was an issue” and “Staff changes meant staff often do not know [person].” Some relatives also felt staff needed more or better training. A relative told us, “Staff were not fully trained for [person’s] particular needs.” Another relative told us, “Staff were not using Makaton [A language programme that combines signs, symbols and speech] or PECS [Picture Exchange Communication System] to communicate with [person].” We then found some staff who worked with the person had not completed their Makaton training while their care plan stated staff were trained in this area.

Staff told us they received regular supervision and appraisals, completed the required training and that people had the necessary staffing support. Staff received a thorough induction upon joining the service. A staff member told us, “The induction was fantastic, did online and face-to-face training, and shadowing.”

We observed there were sufficient staff on shifts and where people needed 1-to-1 or 2-to-1 staff support, these arrangements were in place.

Staff received a range of face-to-face and online training through an in-house trainer and also external training providers. Additional training based on people’s specific needs, such as epilepsy awareness, were provided to staff where needed. Staff also completed the Oliver McGowan training on learning disability and autism. While most staff were up to date with their training, a training matrix revealed a number of staff had not completed certain training in relation to the specific needs of the people they supported. For example, as reported in the ‘involving people to manage risks’ section of this report regarding a person who had swallowing difficulties and was offered unsuitable foods, we found several staff who worked with this person had not completed their dysphagia (swallowing difficulties) training or their training was overdue. Similarly, for another person who displayed physical aggression and had run into the road when they experienced high anxiety, staff had not completed training in physical restraint, which they had had to use to protect the person from coming to harm. Although managers told us staff had completed training in PEG (feeding tube) and buccal midazolam (for people who had epilepsy), these were not evidenced on the training matrix. The above examples highlighted a risk that some people were supported by staff who were potentially not adequately trained in carrying out their roles safely. The service carried out the necessary checks to ensure staff were recruited safely.

People received care and support from staff who were trained in infection prevention and control. They lived in a clean environment and those who were at risk of infections had these risks assessed and managed appropriately by staff.

Staff told us they had access to personal protective equipment and knew when and how to use it. They also told us they supported people to clean their room or flats. One staff member said, “We have a [cleaning] schedule, we put on gloves and aprons, we remove everything when we come out of a bedroom and wash our hands.”

We observed premises were clean and staff followed infection prevention and control practices.

Managers carried out routine checks to ensure premises remained clean and staff were following protocols. Good hygiene practices and cleanliness were regularly discussed in team meetings. The service had an up to date infection prevention and control policy. These processes reduced the risk of infections.

People’s experiences varied regarding the support they received with managing their medicines. People’s preferences for where their medicines were stored were not always considered. We were not assured the service had made arrangements for a person to attend a follow-up appointment regarding a medical condition. We received mixed feedback from relatives on how staff administered people’s medicines. Feedback included, “Medication is administered really well and there have been no errors” and “Not good with medication, staff gave [person] 2 lots of eye drops, lots of incidents with medication with other residents.” Some people who were able to administer their own medicines had the opportunity to do so.

Staff told us they were trained in medicines management and assessed as competent to administer medicines.

Our observations showed there were inconsistencies and shortfalls in how staff managed medicines. We found concerns in several areas including medicines records, stock checks, medicines storage and systems’ effectiveness which varied across the different supported living schemes. People’s medicines records contained discrepancies in some cases. For example, 1 person’s allergy to a medicine was recorded under 2 different names across their records. We found multiple instances where medicines balances differed to what staff had recorded. For 1 person who was prescribed a medicine for pain, the medicine which had a limited shelf life once opened was being used past its use-by date. Although protocols for ‘when required’ (PRN) medicines, such as pain relief medicines, were in place to guide staff when to administer these medicines, the reason for their administration and the outcomes were not always recorded. Also, PRN protocols for some people had not been updated to reflect their current medicines.

Nonetheless, we also observed elements of good practice including staff signing medicines administration records appropriately to confirm people had taken their medicines, and clear documentation of the prescribed medicines, dosages, uses and side effects for some people.

Processes for managing people’s medicines safely were not always robust. Medicines audits were carried out routinely across all schemes but we could not be assured these were effective. When actions were identified in audits, the improvements were not always implemented. Some people were administered medicines covertly (when medicines are administered in a disguised format without the knowledge or consent of the person receiving them). However, not all schemes could evidence that the best interest processes were followed, including the need for covert administration for each medicine prescribed, each time a new medicine was added, or the dose for an existing medicine was changed. While managers assessed staff competency to administer non-complex medicines, there were no processes to assess the competency of staff who administered some people’s medicines through enteral feeding tubes. This meant we could not be assured these medicines were always managed safely. While controlled drugs (CD) were stored securely according to legislation and policy, we found discrepancies in the CD register where staff recorded quantities incorrectly on receipt of these medicines. The service did not consistently record when medicines, including controlled drugs, were returned to the pharmacy. We could not be assured that controlled drugs were being returned to be disposed of safely.

The service addressed medicine-related errors and incidents in isolation. This meant these issues were not systematically recorded to give senior managers the opportunity to thoroughly analyse them across the different schemes to ensure any learning was effective and errors/incidents were reduced.

Some examples of good practice included regular administration of PRN medicines were raised with people’s GPs for review, managers demonstrated adherence to the STOMP (Stopping over medication of people with a learning disability and autistic people) national programme by working with other healthcare professionals to reduce people’s psychotropic medicines where possible, and the implementation of clear medicines records in some schemes.