Head Office Also known as Swindon

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.

This is the first rated assessment for this registered service. This key question has been rated 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 regulations in relation to safeguarding people from abuse, risk management and the way people’s medicines were managed.

This service scored 53 (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. Lessons were not always learnt to continually identify and embed good practice.

Leaders maintained a log of incidents and provided data to monitor trends around the number of incidents, including those involving physical intervention to reduce the risk of harm to the children and young people themselves, staff, family members, and the public. Despite an established process, records did not always show how interventions had complied with people’s positive behaviour support plans. The provider therefore could not judge on review of incident reports whether staff had followed agreed reactive interventions.

Reports did not always include reflective debrief for the staff involved or include sufficient debrief discussions with the young person who had been subject to the intervention.

This meant the provider could not be assured that robust learning had taken place to reduce the risk of recurrence, as actions recorded were not specific, measurable or outcome focused. Consequently, there remained a risk that similar incidents could occur again, potentially placing people at continued risk of harm.

However, staff told us they felt they learned lessons following incidents.In response to our feedback, the provider told us they had implemented a more comprehensive debrief form to help ensure all information would be documented consistently and support learning from incidents.

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.

People had documents to support the safe transitions of people between services. For example, people had ‘hospital passports’ which contained key information about their needs, likes and dislikes. This meant hospital staff would help staff support people safely.

The provider did not work with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Some children and young people were routinely being restrained in ways which were not in line with their care and support plans. For example, out of 3 care plans reviewed where people were subject to restraint, only one of these had details of approved physical interventions recorded in their care plan. Additionally, there was not always evidence these physical interventions had been agreed by a multidisciplinary team in line with the provider’s policy in relation to restraint. This did not ensure people’s safety, dignity and rights were protected. The manager told us that while records were not always completed, staff did assess people to check their welfare and for any injuries after an incident of restraint occurred.

Furthermore, there was no evidence of young people being consistently assessed and observed for ill effects from the intervention, with reference to injury only pertaining to staff or others present, such as parents. Therefore, injuries could be missed and timely medical intervention might not be sought.

However, staff had received safeguarding training which covered both adults and children, and training in physical interventions. Relatives did not raise any safeguarding concerns.

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.

When some children and young people became distressed their behaviour could pose a risk to themselves and others. The risk these behaviours could pose in the home environment and when travelling with staff had not comprehensively been assessed. Additionally, there were further areas of risk which had not been adequately assessed. For example, the risks relating to the use of restraint had not been assessed.This lack of proactive risk assessment and planning meant care was not always delivered in a way that balanced safety with people’s rights, preferences and individual needs, increasing the likelihood of inconsistent or unsafe practice.

However, leaders had assessed some risks such as accessing the community, communication and medication. Relatives did not raise any concerns in how risks were managed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Assessments of people’s home environment had not been completed to determine the safety of the environment care was to be delivered in. This put people and staff at risk of harm relating to the environment such as fire hazards and electrical safety concerns.

However, the provider had assessed general risks. For example, there was an adverse weather policy which detailed what to do in the event of hot or cold weather. Staff had received training in health and safety, fire safety and food safety. Daily records of care demonstrated staff assessed some environmental risks.Young people had personal evacuation plans, a health and safety risk assessment, and an overarching general risk assessment for staff working in the community.

The provider did not always make sure staff were safely recruited or supervised. However, staff had received training relevant to their role.

All required information was not always available to evidence staff had been recruited safely. We identified 2 out of the 3 staff files reviewed had gaps in staff’s employment histories. During the interview notes for these staff, leaders had incorrectly recorded there were no employment gaps. This meant these gaps were not explored with staff to determine what staff were doing in between employment.

Some relatives told us staff came on time and stayed for the full duration. However, one relative raised a concern about not knowing which staff were coming to support their family member. We also reviewed some complaints and found there had been 3 complaints in relation to staff not providing care at the allocated times.

Although staff had received regular supervisions, there was no evidence of anyone being trained in delivering safeguarding supervision or of safeguarding supervision sessions taking place, in line with best practice guidelines for services supporting children. This limited the opportunity for children to have emerging or unknown safeguarding needs identified and limited learning from safeguarding incidents.

However, all staff had received other safe employment checks. Staff had received an induction and training relevant to their role, including specialist training in supporting people with a learning disability. There were enough staff who were deployed to meet people’s needs.

Following the assessment, the provider told us they had increased the focus on safeguarding discussions in staff supervisions to ensure they were meeting the expected standard. The provider also told us they had planned training with all staff to ensure thy had the correct skills to undertake safeguarding supervisions.

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. Staff had received training in infection prevention and control. Relatives told us staff wore personal protective equipment where appropriate and kept people’s environment clean. There was a policy which outlined procedures for staff and staff were aware of this.

The provider did not always make sure that medicines and treatments were safe.

Information about the support people required with their medicine was not always up to date. Inconsistent and unavailable information for staff put people at risk of receiving medicines incorrectly, which put them at risk of harm.

The same person did not have a mental capacity assessment and best interest decision for the administration of medicines where required. This meant there was no legal framework for staff to be administering the person’s medicines.Following the assessment, the provider told us they had implemented a more robust process for the completion of capacity assessments to ensure compliance.

Another person’s care plan stated their medicines needed to be mixed together with some food due to their preferences. There was no evidence the provider had ensured this was safe with a medical professional. This meant we could not be assured the person was receiving their medicines safely. The manager told us they would stop administering the person’s medicines in this way until it had been agreed by a trained professional.

However, relatives told us they felt medicines were managed safely. There was a policy which outlined procedures for staff. Records showed people had received their medicines as prescribed, and staff were trained and competency assessed.