New Partnerships Lynray and Peach Cottage

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 to staffing.

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 had a culture of safety, based on openness and honesty and where investigations were undertaken learning was shared with staff. However, relatives expressed concern about some of the things that had gone wrong and the providers lack of foresight. They told us that assurances had previously been given but these have not always led to meaningful change or improvements in the quality of care.

We found that staff completed daily logs and recorded accidents and incidents, but records were not always detailed. Analysis was not comprehensive and there were gaps in recording which impacted on the providers ability to learn and improve.

The provider responded to our feedback and told us that they were making changes to staff meetings to ensure more reflection and learning. They showed us information they had obtained from their quality systems which they intended to immediately review and discuss with staff.

People did not always experience continuity of care when they moved between different services. A person recently became unwell, and they were admitted to hospital, staff did not follow the providers procedures or their training to ensure a smooth transition. We saw that the provider had investigated and taken action however this event indicated that safe systems were not yet fully embedded.

The provider worked with people and partners to understand what being safe meant and shared safeguarding incidents appropriately with the relevant agencies. Staff told us that they had completed training but some of those we spoke to were unclear about the actions that they should take and the reporting procedures.

The provider worked with people to understand and manage risks. There were risk assessments in place to support people, such as for travelling in the car and to manage health conditions such as epilepsy. Personal emergency evacuation plans (PEEPs) were in place to record what support people would require leaving the service in the event of an emergency such as a fire.

The guidance for staff to support people who experienced distress was not in place. Relatives told us that some work had been undertaken over an 18-month period, but these plans were still in draft and not yet in use. We saw that incidents had occurred there was a lack of clear guidance for staff, and this presented risks which were not yet mitigated. The provider told us they were working with a specialist behaviour specialist and were collating data on behaviours and would use this to update the positive behaviour plans.

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 audits were undertaken to check on safety. Equipment was serviced and repairs undertaken. We saw that a person had recently fallen on the stairs, but the provider had fitted carpet to reduce the risk to the person. We saw that some cleaning chemicals were not safely stored but we were assured by the provider that they would take immediate action to address this and keep people safe.

The provider could not always demonstrate that there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There were gaps in staff knowledge and there was no evidence that staff were supported to develop their skills and undertake additional qualifications. Staff spoken with as part of the assessment were not always knowledgeable about safeguarding procedures, mental capacity or first aid procedures, despite being recorded as having successfully completed eLearning. Only two staff had a NVQ qualification. One member of staff told us, “The training is basic….it’s a tick box exercise.”

Relatives did not have confidence in the skills and knowledge of staff. One told us, “I don't think the training is adequate at all and when they do have new staff, which is regularly, they get current staff to train them. So, for me it's like the blind leading the blind.” Another told us, “Well, there's one or two staff that are, that do understand (my relative), and I've got full confidence in, but there's lots of staff there that don’t.”

The assessment identified issues regarding staff deployment and shift leadership. Some people were in receipt of one to one or two to one support, but we observed that some people spent significant periods in their bedroom alone, and staff undertook cleaning duties or sat in the communal area. For example, a member of staff who was working with one person on a one-to-one basis had left the service to collect staff and another person as they were the only driver available. This meant that the member of staff was not available to support the person they were allocated and funded to support.

Management staff were available on site to support staff during office hours but outside these hours the service was overseen by a practice lead or on call. There was a vacancy for practice lead and on alternative weekends there was no shift leader. The provider told us that they had made a staff appointment and were continuing to recruit but given the shortfalls identified in staff knowledge and expertise we had concerns about oversight. The provider responded by putting in interim management arrangements to ensure cover on alternative weekends.

The shortfalls we identified regarding staffing are a Breach of Regulation 18 [staffing] of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014

There had been recruitment since our previous inspection when the provider was using a significant amount of agency staff. Agency usage had decreased and where agency staff were used efforts were made to use regular staff. One relative told us, “The situation was worse about twelve months ago when, staffing issues were escalated in the company. There seems to be more stability now, less agency staff, but I don't really have confidence in many of the staff. It used to be very different.”

Staff were safely recruited. Pre-employment checks and disclosure and barring checks were undertaken. Confirmation on the checks completed on agency staff were sought prior to them working at the service.

The provider maintained a clean and uncluttered environment. Cleaning schedules were in place and staff ensured that all areas were regularly cleaned. The service smelt fresh and there were no malodours. Staff confirmed that they had access to personal protective equipment when they needed it.

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

Staff had completed training in the safe management of medicines, and their practice was observed on a regular basis to ensure that they were following policy and procedures. Staff maintained accurate records of medicines they administered. We checked a sample of medicines and found that they were appropriately stored, and the amounts tallied with the records. Records showed that where anomalies were identified these were escalated for investigation. Where people were prescribed as and when medicines (PRN) for distress or constipation plans were in place to guide staff as to their use.