Archived: Dr J & Colleagues

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 toRequires 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.

This service scored 41 (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 always have a proactive and positive culture of safety based on openness and honesty where lessons are learned and shared to continually identify and embed good practices.

Although the service had processes for incident reporting and lesson sharing, staff did not consistently use them. Many were unaware of the formal procedures for reporting incidents and complaints, and some could not explain how learning from incidents was shared or led to service-wide changes. Lessons were not always learnt to continually identify and embed good practice. We identified repeated errors, including assessment reports and prescriptions being sent to the wrong person. Staff reported the absence of a formal debriefing process following serious incidents or complaints. Despite our request, the provider failed to supply an adequate policy for managing safety incidents.

However, we found the management team were open and transparent and wanted to drive improvement at the service. Staff also told us that they felt safe to raise concerns directly with the registered manager. There was some evidence that safety incidents and complaints were investigated. Leaders also held a weekly meeting to discuss complaints and lessons learnt. The administration team held regular meetings and collected feedback from staff. We saw evidence that their suggestions to improve the role and efficiency of the team has been taken into account and changes had been implemented.

The service did not always work with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. They did not always ensure continuity of care, including when people moved between different services. A review of the provider’s complaints log identified that some appointments were cancelled due to issues with the provider’s Right to Choose NHS contract. As a result, people reported being left without medication unless they paid for treatment privately. Our review of care records also found that in one case, a parent did not provide GP details during the assessment, which meant clinical information was not shared with the GP. There was no clear process in place to ensure follow-up when GP details were missing during ADHD and/or autism assessments, raising concerns about continuity of care and information sharing.

The service did not always work with people and healthcare partners to understand what being safe meant to them. The service did not always operate safeguarding systems and processes effectively to protect people from abuse. Some staff were unclear about the service’s safeguarding policy and could not identify the designated safeguarding lead (DSL) responsible for overseeing safeguarding. Our review of the safeguarding policy revealed key omissions, including the name of the DSL and contact details for local safeguarding partners, raising concerns about the policy’s effectiveness and accessibility.

However, staff received safeguarding training and demonstrated the ability to identify when a child or adult might be at risk of harm. They could recognise various forms of abuse and the associated warning signs. In two recent safeguarding cases we reviewed, staff took appropriate action by escalating concerns to service leaders and collaborating with external agencies to protect individuals. Staff also showed a strong understanding of the Mental Capacity Act (MCA). Our review of 12 care records confirmed that mental capacity had been assessed and documented appropriately.

There is a clear understanding of the requirements of the Mental Capacity Act (MCA), and staff demonstrate how they put these into practice effectively.

The service did not work well with people to understand and manage risks. Our review of care records showed that whilst assessment of risk had been considered. The provider did not consistently use a recognised risk assessment tool in line with guidance. For example, care records lacked the level of detail recommended by the National Institute of Care Guidance (NICE). One record did not include a treatment plan and failed to provide a thorough analysis of symptoms or consideration of co-existing conditions. There was no consistent approach to gathering historical information. For example, some clinicians contacted schools directly to support the assessment process and to share care plans, while others relied solely on written forms completed by educational staff. In several ASD assessments, there was no evidence of input from educational settings, which is a key component of a holistic developmental assessment. It was also not always clear whether clinicians had explored or ruled out co-existing neurodevelopmental or mental health conditions, which is essential for accurate diagnosis and appropriate intervention.

We did not look at Safe environments during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

The provider made sure there were enough qualified, skilled and experienced staff to provide safe care that meets people's individual needs. Staff were up to date with appropriate mandatory training. Data showed that training compliance was 100% for all modules. Staff completed a range of training which were appropriate for the service. However, the service did not offer specific learning disability training in line with guidance. Contracted staff transferred learning from different training providers, and we didn't see any evidence that the training had been reviewed by the provider. Staff did not always receive regular supervision. The supervision compliance rate at the service for contracted staff was 86% and the appraisal compliance rate was 65%.

We did not look at Infection prevention and control during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen. There were clear roles and responsibilities for non-medical prescribers in the titration team, and staff followed good practice in medicines management in line with national guidance. However, formal auditing of prescribing practices among non-medical prescribers was not robust and it was unclear who had responsibility for managing drug safety alerts.