Archived: 1 & 2 Flax Cottages

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 inspection we rated this key question good. At this inspection 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 provider was in breach of legal regulation 12 (safe care and treatment).

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.

The provider did not always have a proactive culture of safety. The acting manager had identified and acted on a number of areas of safety that needed improving. They and the area manager recognised the need to improve the culture of learning and safety.Safety considerations had not always been dealt with as openly or promptly as they should have been in the past, meaning there had been some missed opportunities for learning. This contributed to some risks being overlooked or not dealt with effectively enough.

Relatives confirmed they had not always known how to raise issues. One said, “Trust is a big issue. I don’t know who I can trust or who to go to. The old manager never introduced herself to me, I wouldn’t have known who she was.” They and others commented, “The new manager is nice,” and had that they were beginning to build confidence in the acting manager.

The provider was committed to making improvements and staff felt able to raise any issues, knowing their leaders would now listen. Policies and procedures had regard to national safety alerts and good practice. The provider had a system in place to share national safety alerts and advice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The acting manager had begun reviewing the provider’s electronic care records systems, to ensure people were supported to access the care and support they needed, and to identify areas of risk. There were some positive examples of detailed, up to date record keeping in people’s care plans.

Personalised Emergency Evacuation Plans (PEEPs) were in place, up to date and detailed.

The provider had long-established relationships with local health and social care professionals, although they had not always referred relevant matters to them in as timely way as possible. The provider recognised this and had taken steps to make improvements.

People and relatives did not have any concerns about their safety. They gave examples of where they had raised issues recently, and how these had been dealt with efficiently, particularly by the acting manager and the area manager. Relatives felt this effectiveness was a recent development and reflected on what they saw as improved openness and approachability in comparison with the previous registered manager. The acting manager had identified and acted on safeguarding matters, for instance unexplained bruises. Previous safeguarding matters, prior to the acting manager starting, had not always been acted on as promptly. Because of these delays, people’s opportunity to thrive had been reduced.

Staff communicated with people well and demonstrated a good understanding of people’s non-verbal cues. People were well supported when they were upset or concerned about something, from staff who demonstrated compassion and empathy.

Policies, procedures and training were in place to ensure staff were equipped to recognise and escalate safeguarding concerns.

People and their relatives were not always involved in assessing risks. The provider had not always fully taken the perspective of people who used the service when assessing risk and impact. For instance, people were without a bath in their own home for a number of months. The provider had put in place alternative arrangements, but these presented potential additional risks that had not been fully reviewed and documented.

There were other instances where sufficiently detailed risk assessments and preventative measures were not in place or not described. These included where people may have particularly anxious reactions. The provider had not sufficiently utilised Positive Behaviour Support (PBS) or similar strategies to help people and staff manage risk. PBS is a person-centred framework for providing long term support to people with a learning disability, and/or autism, including those with mental health conditions, who have, or may be at risk of developing, anxious behaviours.

The provider had yet to comprehensively review and implement people’s goals and aspirational plans, including ensuring there was a level of positive risk taking.

People felt safe and their relatives raised no safety concerns. One relative said, “They are always clean and tidy and there have never been any concerns with staff.” One person said, “The staff are amazing, can’t do enough for me and I have no problems at all.”

The new manager and area manager were receptive to our feedback and took action to immediately begin improvements in this area.

The provider did not always detect and control potential risks in the care environment. There were some hazards at the service that had not been adequately dealt with. To the rear of the bungalows there were a range of bulky items and other items of waste that needed disposal. The provider actioned this following the first day of inspection.

A summer house was inaccessible, and the provider recognised this needed replacement; the other summer house was full of confidential and other information which needed archiving – the storage was not suitable and safe. The provider actioned these following the first day of the inspection and had plans to replace a summer house. Inside, one bathroom was used to store mobility equipment as the bath was not working at the time of inspection.

People felt at home and had decorated their own rooms in personable ways. They knew their way around their service, which had wide corridors, although the laundry and kitchen were not well adapted for wheelchair acces

The provider made sure there were enough qualified, skilled and experienced staff. People had confidence in staff, who they knew well for the most part, and trusted with day-to-day tasks, personal care and support. They felt safe. Staff were committed to their roles and took action to ensure people were safe and looked after on a day-to-day basis.

There was some reliance on agency staff but the impact of this had been minimised by the provider ensuring they used the same agency staff consistently. Some staff had been at the service for a long time and were strong advocates for people.

One person said, “The staff are all spot on, they never stop.”

The provider completed appropriate recruitment checks for new staff to ensure the risks of unsuitable applicants working with people who may be vulnerable, were reduced. Staff received training including training specific to the needs of people who used the service.

There were some areas requiring immediate improvement in terms of infection prevention and control. This included rusted support rails in the bathroom and some high traffic areas needing improved cleaning. People’s toiletries were not always stored safely. Storage was recognised as an issue by the provider; they had been storing PPE and excess continence products in outdoor sheds, which were not appropriate for the purpose.

The provider took actions to improve in these areas during the inspection.

Staff worked hard caring and supporting people. They completed cleaning and laundry tasks when they had the time. The provider needed to review the effectiveness of this and the support in place for staff. Staff received infection prevention and control training as part of their induction and the provider had outbreak and infection prevention policies in place.

People’s medicines were managed safely. Staff had received training in how to administer medicines. Medication competency checks were in place and people’s medicines were reviewed regularly by clinicians.

The provider’s policies regarding medicines were up to date and in line with good practice. Training was in line with STOMP (Stopping Over Medication of People with a learning disability and autistic people).

The acting manager and other leaders had undertaken audits to ensure standards were maintained. Where errors were identified these were acted on promptly.