The Bungalow

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 Good. At this assessment the rating has changed to 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 regulations in relation to safe care and treatment.
 

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Incident records were not effectively analysed. Incident reviews consisted largely of chronological descriptions rather than identifying themes, patterns, triggers, underlying causes or opportunities for prevention.

There was no evidence that learning from incidents was used to develop proactive strategies to reduce the likelihood of recurrence. Management oversight of behaviour assessment charts and self-injurious behaviour records was insufficient, limiting opportunities to identify trends and implement improvements. Audit systems failed to identify all incidents occurring within the service.

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

Risk assessments and care records contained inaccurate and out-of-date information. Staff were not always able to identify the current version of documents; this posed a risk when people were moving between different services. Risks were not consistently assessed or mitigated, increasing the risk of unsafe care and treatment.

People’s movement between their main place of residence and the service was supported effectively, people had communication books that were used to share information about changes in people’s needs between visits to the service.
 

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.

There were concerns regarding the provider's ability to maintain safe systems that protected people from harm. Staff did not consistently investigate the causes of injuries sustained by people and often attributed injuries to self-injurious behaviour without sufficient investigation and follow-up. Record keeping relating to restrictive interventions and incidents was incomplete, reducing assurance that safeguarding concerns would be identified and reviewed appropriately.

However, a person’s relative told us they had no concerns about the person’s safety and wellbeing, they told us, “[Person’s name] seems quite happy there, they would tell me if they weren’t. I’m generally happy with the care.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that appropriate DoLS applications had been made, and where there were delays in these being authorised by a supervisory body these were chased up by the management team.
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessment and care planning systems were not consistently effective. Peoples' risk assessments contained outdated and inaccurate information, including instructions relating to equipment no longer in use.

Multiple versions of risk assessments existed, causing difficulties in identifying current information.

Risk assessments did not always fully address identified hazards. For example, environmental adaptations intended to protect a person at risk of self-injurious behaviour did not consider all relevant hazards within the bedroom environment. In addition, risk management guidance for another person included inappropriate first aid measures. These issues placed people at risk of receiving unsafe or inappropriate care.
 

The provider did not always 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.

People were not always protected from environmental risks. The provider had not ensured the premises were well maintained, secure or safe. We identified a range of hazards, including trip risks, ineffective security measures and unsafe storage of waste and hazardous substances. For example, clinical and general waste bins were not secured, and cleaning products and other COSHH materials were accessible. This placed people at risk of accidental harm.

The provider was already aware of the deficiencies in relation to environmental safety and had a plan in place to improve the environment. However, action had not been taken promptly enough, and this had placed people at risk of harm.

Fire safety processes were not always effective. Records of fire drills lacked important information, including when drills took place, which staff were on duty, and which people were using the service at the time. Fire drills had only been completed during the day and there was no evidence of night-time drills. This reduced assurance that staff would be able to respond appropriately in the event of a fire.

The provider deployed sufficient staff and had arrangements in place for staff training, supervision and development. However, recruitment records did not always demonstrate that all required checks had been completed, and staff practice did not always ensure people received safe care that met their individual need.

A recruitment policy was in place which supported safe recruitment practice. However, not all staff files contained evidence the necessary recruitment checks had been carried out. For example, there were gaps in employment history for some staff that had not been explored.

The provider deployed sufficient staff to meet people’s needs and training records demonstrated staff had received suitable training for their role. One member of staff told us, “Training is refreshed every year and I’m currently being supported to do a diploma.”

Staff told us they received regular supervision and were encouraged to develop their skills, one member of staff said, “It is helpful, we can tell them our concerns, training needs, we talk about how we are improving, I feel listened to”.

However, the findings of this inspection indicated the training and support in place did not always result in staff working in a way that ensured people received appropriate care and support.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Infection prevention and control risks had not been effectively identified or managed. We found damaged equipment that was difficult to clean, unclean storage areas, dirty extractor fans, inappropriate waste management arrangements and concerns regarding the separation of laundry and kitchen areas. Governance systems had failed to identify and address these issues, increasing the risk of cross-contamination. The provider acknowledged the findings of the assessment in relation to infection prevention and control and had a plan in place to make improvements. However, action had not been taken promptly enough, and this had placed people at risk of harm.

Food hygiene measures were not implemented effectively, as food was not always stored safely. For example, records showed that freezers had consistently been running at a higher than safe temperatures. Until these concerns were identified during the inspection no action was taken.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Safe systems were in place to ensure people’s medicines were safely booked in and out of the service. People received their medicines as prescribed, and staff followed appropriate procedures for administration. Where people required medicines on an as required basis, we saw these were managed appropriately.