Sugarman Health and Wellbeing - Dorset

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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff reported accident and incidents, and these were investigated by management. The registered manager had systems and processes in place to share learning with staff to drive improvement. A staff member told us, “The team does get feedback and if there are changes or tracking required in the case, we are informed.”

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.

Peoples’ needs were assessed prior to people receiving a service and a guide was in place to provide additional support for the transition. There was a process for sharing information when people moved between services, for example when they went into hospital.

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. They did not always share concerns quickly and appropriately.

During the inspection, inspectors identified the registered manager failed to report all safeguarding incidents. This meant the provider did not receive appropriate external challenge and scrutiny to help support and drive learning within the service. In response to our feedback, the provider reported safeguarding incidents retrospectively to the local authority.

People told us they felt safe with support they received from staff. One person told us, “Most of my carers have been with me for a long time so I feel safe.”

Staff had received training and knew how to report safeguarding concerns.

The provider worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Detailed care plans and risk assessments provided guidance to staff, enabling them to support people in line with their needs and preferences. These were regularly reviewed with people. People were supported to be engaged in positive risk taking, such as participating in community activities and going on holiday. Staff told us care plans and risk assessments were updated when people’s needs changed.

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

People’s home environments had been assessed for potential risks during the pre-assessment process. Staff had received training in the safe use of equipment, including equipment used to help people move around their home. Staff told us they knew how to report any concerns to management, including when people’s needs changed.

The service did not always ensure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider could not be assured staff had skills relevant to people's needs. For example, while staff had received some training in relation to learning disabilities and autism, no staff had received training in line with the recognised code of practice. The provider failed to work in line with their policy and best practice guidance. For example, no staff were receiving competency checks regarding their moving and handling practice. This meant the provider could not be assured staff had the correct skills and training to support people safely.

Staff completed induction, which included shadowing experienced staff. Staff continued to receive regular supervision. The provider followed safe recruitment process, and appropriate checks were carried out before staff commenced employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

People told us they felt safe with support from the care staff. One relative told us staff were, “Very knowledgeable of [persons] needs. I feel like they know what they are doing.” Staff told us they received person centred training they required to support people. One staff member said, “Additional training is provided depending on the needs of the individual client.” Another staff member told us, “The team works welltogether, and there is a strong focus on delivering safe, compassionate, and high-quality care.”

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.

People were protected from the risk of avoidable infections. A process was in place to ensure staff had access to sufficient personal protective equipment. Staff received infection prevention and control training, and their use of personal protective equipment was monitored during spot checks of their practice.

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

People received their medicines as prescribed. PRN (as and when required) protocols were in place to guide staff on when to administer these medicines. Regular audits were carried out to identify any concerns. Staff received medicines training and checks of their practice, however these required developing to ensure staff had developed the skills required to administer medicines safely. The registered manager told us of their plans to implement a medicines competency assessment document.