The Cotswolds

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people were not always safe and protected from avoidable harm.

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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider operated a lesson learnt newsletter for staff, as well as learning outcome forms which they shared with staff at all levels. These included internal and external incidents, to learn from other providers and people’s experiences and ensure measures were in place to avoid the same experiences for people.

We found evidence that systems to learn from incidents were effective and thorough, for example, the implementation of a new system for staff to follow, if someone were to leave the building unsupported.

The provider was working to an action plan, which was developed following their own internal audits, Integrated Care Board feedback, and Local Authority feedback. There was a culture of continuous improvement, at service level, as well as for the wider community of people living with a brain injury or living within a similar service.

Some staff were confident in the management’s ability to thoroughly investigate and feedback following incidents or accidents that they had reported, however some staff did not feel they were involved.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

The provider had systems and processes in place to aid emergency situations, or urgent movement between services, such as hospital admissions. The provider had Situation, Background, Assessment, Recommendation (SBAR) communication tools in place, which is a method used in the NHS to enhance patient safety and effective information sharing, along with other useful tools to ensure information about people would be shared in different situations.

Staff didn’t always feel that they were given time to read information about people, particularly for someone new moving into the service.

Some personal emergency evacuation plans (PEEPs) did not contain details on how to evacuate people from multiple circumstances. For example, if they were in bed at night, the evacuation method may be different to if they were in their chair during the day. This meant some people were at risk of unsafe, or delayed evacuation as staff and emergency services would not have been provided with clear information. The provider took prompt action to rectify this after this was fed back to them.

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 had a robust safeguarding policy in place, which included information for staff to raise concerns externally.

Within the service, there was information available on display boards, for both staff, people and relatives on safeguarding procedures and preventative measures.

There was a designated safeguarding lead in post, with a clear set of responsibilities, this was also displayed around the home. Some of these posters and information leaflets were available in an easy-read or pictorial format making the information accessible to most people. Staff and leaders had completed safeguarding training.

The provider was working to and upholding the Deprivation of Liberty Safeguards (DoLS). This is a safeguarding measure, for people who cannot consent to their care, treatment or any restrictive measures in place for their safety.

The provider did ensure staff were trained in Deprivation of Liberty Safeguards, however, more needed to be done to ensure that knowledge was embedded, as there was a gap in knowledge amongst the staff team.

Care providers are required to submit statutory notifications, when certain types of events occur. The provider was submitting these to us and had a system in place to ensure events were reported to all relevant place, investigations took place and outcomes were shared.

We saw evidence that Duty of Candour was being upheld. People, relatives or representatives where kept informed during the provider’s investigation.

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 supportive and enabled people to do the things that mattered to them.

The provider had the relevant plans and assessments in place to manage and mitigate risk, however there was room for improvement to ensure people were supported to be involved, or have the relevant information adapted into a format they may understand.

Where there were risks such as choking, or falls, this had been assessed by relevant members of the multi-disciplinary team, and information was provided on how to manage these risks for the staff and other people or professionals involved in their care. We found that some people were supported with positive risk taking, such as working to achieve more independence, even where they may be some risk attached, however this was not consistent for everyone.

When people experienced emotional distress, the provider had plans in place on how to support them with this, and restraint was used as a last resort. The provider would work with the person, sometimes indirectly, to look for patterns or themes within their distress or behaviour that communicates and aim to reduce the frequency for that person.

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

The provider followed most relevant legislation relating to safe environments, for example, Portable Appliance Testing (PAT) and fire alarm and panel servicing. However, we did find that they were not adhering to the Lifting Operations and Lifting Equipment Regulations (LOLER regulations 1998) frequency, this was addressed promptly by the provider when brought to their attention.

The provider had a maintenance team who were responsible for identifying and rectifying safety concerns with the environment, as well as regular audits, and environmental checks to ensure they had oversight. Staff and leaders also had a role to play in maintaining safe environments, and we found there was a team-based approach to this aspect. There were regular checks on environmental safety measures such as water temperatures and fire systems.

The provider was currently doing environmental work to the service, for example, painting, decorating and renewing flooring. This had not been completed across the whole service at the point of our assessment, so we did find some minor concerns. However, we were assured that the provider was working through their refurbishment plan, and they were able to evidence where they had booked external organisations to complete work, coming up in the very near future.

We found during our assessment some practice issues, where staff were not adhering to policies and procedures. For example, in one of the lounges, we found a fire door propped open meaning it would not be able to close in the event of a fire leaving people at risk, and moving and handling equipment stored partially blocking an open-door which left people at increased risk of falls. This was shared with the provider and addressed immediately. They increased their frequency of management walk-arounds in response to this, and other aspects of our feedback.

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 were recruited in line with safe recruitment processes, including Disclosure and Barring Service checks and multiple references from different sources.

The provider had interviews formulated with relevant questions to ascertain someone’s suitability for the role, using a scoring system. This system was not always used and there were some examples where the interviewer did not thoroughly detail the persons answer, or record anything for some questions. This practice changed before the end of our assessment.

Staff were able to access and were expected to complete training providing them the knowledge and skills to deliver aspects of their roles, however, there were some gaps in training, where staff had not all completed it. The courses this pertains to, did not put people at risk or stop staff completing the basic tasks of their roles; however, it could have impacted people’s experiences of care within the service.

The provider employed Nurses, Occupational Therapists and a Social Worker, along with many other professions. They had a system in place to ensure people’s registrations were up to date, where necessary, and were working to develop their skills within their individual professions by introducing additional training.

Staff, and some relatives felt there wasn’t always enough staff. Some relatives felt that at the weekend there were less staff, however, staff felt that it was all the time. Staff reported that they had enough time to do the basics and mandatory tasks of their role but didn’t not have time to do anything meaningful with people using the service. One staff member told us “I feel quite guilty, because I feel like I’m not able to give the best standard of care I’ve always given at the moment and that upsets me.” The provider used a needs-based dependency tool which is regularly reviewed, and they were providing the right number of staff against that tool.

Some staff also reported that although supervisions are regular, they are not always meaningful, and it can sometimes feel like a tick box exercise and rushed.

The provider assessed and managed the risk of infection. They took steps to detect and control the risk of it spreading.

The provider had a clear policy, as well as systems and processes in place to detect and respond to any infection risks.

Staff were knowledgeable about how to use personal protective equipment (PPE) including appropriate disposal, and how to respond to an infection outbreak. People and relatives did not share any concerns around the cleanliness of the home or hygiene. Some staff felt the provision of PPE wasn’t always sufficient, and often they would find it certain items such as gloves, in short supply.

The provider employed cleaners who are deployed to different areas of the home. Staff reported that the cleaners are always too busy, and often don’t have time to complete deep cleans, and are mostly cleaning on surface level. There was room for improvement to ensure all aspects of the service were cleaned thoroughly, for example, we found some wheelchairs were not cleaned to a hygienic standard.

On our assessment, we found that there was some flooring which over time had become scratched and scuffed. This posed a risk as this could harbour bacteria. The provider had already identified this and were working to a refurbishment plan, and this was replaced during our assessment.

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 had a robust medication policy, which included best practice guidance such as guidelines provided by the National Institute for Health and Care Excellence (NICE).

There had been a recent increase in medication errors, which had been determined to be due to more frequent use of agency staff. The provider altered agency staff’s induction process following these incidents to prevent recurrence.

We found some concerns with medicines practice within the service. For example, medicines administration records (MAR) had not been fully completed, sometimes missing the balance counts or staff signatures. The provider utilised PRN Protocols for their pro re nata (as required) medicines. This is a tool to ensure that staff can access the necessary, person-centred information to safely administer PRN medicines, promptly. There was not always sufficient information on these. Additionally, it was the same where someone required their medicines to be administered to them covertly, the provider had followed all the legislation required to implement this practice, but had not acquired or documented information such as, which foods and drinks certain medicines can, or cannot be administered in.

The provider began to rectify these concerns before our assessment ended, and some things they had already identified and were part of the action plan they were working to.