Plean Dene

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 regulation in relation safe care and safe staffing.

This service scored 62 (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.

Staff demonstrated a robust understanding of actions they needed to take in response to a safety event. Records showed the registered manager analysed safety events and shared any learning effectively with staff. This reduced the risk of similar safety events occurring in the future.

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.

Staff demonstrated a robust understanding of the importance of sharing information when people transitioned from the service. The service continued to support a person after they moved to provide consistent support.

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.

There were appropriate policies in place to protect people from abuse and staff had training in safeguarding adults and children. Staff could describe actions they would take if they suspected or saw abuse. Contact numbers for the management team, the local authority safeguarding team and Care Quality Commission were also available to staff. The management team knew what action to take if concerns or safeguarding issues were passed to them. Records showed the registered manager had reported and investigated incidents appropriately and promptly when required.

Where people were deprived of their liberty, Deprivation of Liberty Safeguards (DoLS) applications were made to legally authorise restrictions placed on people to keep them safe.

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.

Some risks had been identified and support measures put in place to manage risk and prevent harm however this was not consistent.

People were assessed for the risk of falls, choking, malnutrition and risks relating to medical conditions. Some actions identified had not been implemented or fully embedded placing people at risk. For example, a person had a mobility risk assessment in place, control measures included using equipment when outside, this equipment was not in use or available during the inspection. The upper area of the garden was accessed by steps and had a steep slope. During the inspection the person accessed this part of the garden, and inspectors had to provide them with support to prevent them from falling. The risk of the person using this area had not been assessed and actions had not been taken to mitigate the risk.

The provider failed to balance the benefits of an activity against the risk, this meant people were not given the opportunity to develop daily living skills or experience activities they may enjoy. For example, people were not encouraged to cook meals or complete their laundry.

The provider was responsive to our concerns and took action to improve the management of risks to people.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety and fire safety risk assessments were completed. Regular audits were undertaken to ensure the environment and equipment remained safe to use. Any concerns were reported to the management team or appropriate person for further action.

Some heavy furniture had not been fixed to the walls, increasing the risk of injury if a person pulled the furniture over. The provider was responsive to our concern and took immediate action to fix all heavy furniture to walls.

The provider made sure there were enough qualified, skilled and experienced staff. However, they did not always work together well to provide safe care that met people’s individual needs.

Some staff lacked confidence to ensure people were engaged in meaningful activities whilst they were at home, and staff were often very busy and not able to provide meaningful support for adequate periods of time. Although staff had completed training in positive behaviour support and autism this was not always effective in practice. This was because staff sometimes failed to support people to live their lives as independently as possible and limited their choices. This meant people’s opportunities to progress were therefore limited.

The provider had some awareness of this prior to our inspection and had employed an activities co-ordinator to work at the service, however more work was required to ensure people’s wellbeing needs were being met.

The provider had recruitment processes which were fair and ensured there was no disadvantage based on any specific protected characteristic. However, the provider did not follow safe recruitment practices. Pre-employment checks had not always been completed when recruiting staff. We checked recruitment records and found the provider had not always sought full employment histories, this increased the risk staff unsuited to care work would be employed in the service. The provider was responsive to our concern and immediately took action to obtain full employment histories of staff.

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.

The provider had a robust up-to-date Infection Prevention and Control (IPC) policy and staff attended IPC training. Staff used Personal Protective Equipment (PPE) when needed, understood how to stop infections spreading and spot checks were completed regularly. People were encouraged to maintain their personal hygiene and reduce the risk of infections from spreading.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff received medicines training, and their competency was checked to ensure they could administer medicines safely. Staff supported and involved people to manage their medicines. Records showed people received their medicines as prescribed.

The registered manager told us, during people’s annual health reviews, Stopping Over Medication of People with a learning disability and/or autism (STOMP) plans were reviewed. This meant people’s medicines were reviewed to ensure psychotropic medicines were not inappropriately prescribed or overused. We saw evidence of people’s medicines being reduced or stopped. This meant people were less likely to be at risk of medical restraint.