Jackson House

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.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Low-level incidents were not always appropriately reported or escalated. For example, minor verbal comments made towards people had not been reported as staff had not always recognised this could be upsetting to other people. This meant opportunities to learn from events were sometimes missed and necessary updates to care plans were not always completed. While incidents were subject to management review, the provider had not identified this gap, resulting in reduced oversight to identify emerging trends and themes. We fed this back to the registered manager who put in place a corrective plan of action to embed incident reporting and systems to strengthen learning and support continuous improvement going forward. Staff told us they understood how to raise concerns, indicating awareness of the reporting process.

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.

Information relating to people's health conditions was not always clearly documented within care plans. For example, information about depression, dysphasia or diabetes. This increased the risk that staff may not have access to key information needed to provide safe and consistent care. Any shortfalls were immediately addressed by the registered manager.

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.

We found some low-level safeguarding concerns were not always reported. Incidents of verbal abuse were not always recognised as an incident with the potential to cause harm and were not always reported or managed appropriately. Processes needed to be updated to manage such incidents appropriately and strengthen safeguarding oversight and promote a proactive approach to risk management. Staff were observed interacting with people in a respectful manner and routinely checking on their safety. Safeguarding systems and processes were in place, and staff had received appropriate training. The registered manager had recently undertaken additional safeguarding training, and arrangements were in place for this learning and incident reporting to be cascaded to the wider staff team.

Where required, appropriate applications to deprive the person of their liberty under the Deprivation of Liberty Safeguards (DoLS) had been made. A monitoring system had been recently implemented to ensure DoLS were reviewed on a regular basis. Significant events which occurred were appropriately reported and analysed.

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

Care records did not always provide sufficient guidance to support safe care. Some care plans and risk assessments needed further details including key information regarding diabetes, choking and people using razor blades. However, staff demonstrated a calm and proactive approach, using distraction techniques to reduce agitation and promote positive engagement. Following feedback, the registered manager took timely action to review and strengthen care plans and risk assessments to provide clearer guidance and include important information.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Systems were in place to ensure the environment was safe. Health and safety certificates were in date and staff carried out regular routine safety checks. Staff had received fire safety training, and fire drills were regularly carried out. Some areas of the environment required attention, such as damaged bedrooms walls and this was being actioned.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were recruited safely and completed a 6-month induction process. Staff confirmed they received sufficient and regular training both face to face and on-line. This included mandatory training in learning disability and autism. One relative told us, "Staff are very kind at Jackson House and that’s the most important thing."
 

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.

Regular infection prevention and control (IPC) audits were carried out; staff had access to sufficient personal protective equipment (PPE) and had received training in IPC to support safe working practices. We found one area that required a deeper clean, however, this was immediately incorporated into the cleaning schedule to reduce the risk of it being overlooked.

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.

Staff had not explored with relevant healthcare professionals whether the timing of prescribed medicines could be varied to reflect a person's established sleep and wake cycle. Medication labels had not been updated following GP-directed dose changes, creating conflicting information and increasing the risk of administration errors. Instruction protocols for medicines prescribed 'when needed' had not been updated with current information and some had not been reviewed for over 18 months. There was no clear system to record the time medication had been administered to people. On receipt of feedback, staff immediately sought advice and tailored medication administration guidance to a more person-centred approach in line with the person's lifestyle and sleep pattern and a full review of medications was under undertaken to strengthen safer medication processes.

Medicines were stored securely and only administered by staff who were suitably trained. Maximum and minimum temperatures were monitored daily to ensure the medicines were stored safely.