Harp Place

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 assessment for this 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.
 

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. The provider did not always identify concerns about safety and did not always investigate, report or learn from safety events.
The provider did not always record lessons learnt, tracked actions, shared information appropriately or checked whether improvements had been embedded in practice. This reduced the provider’s ability to show how safety events led to lessons learnt and sustained improvement.
There had been events that required recording, review and escalation; however, the provider did not identify or investigate them appropriately.
The provider demonstrated some learning from one incident by arranging additional staff training. However, this was not supported by a consistent system to record, share and embed learning following incidents. This meant the provider could not demonstrate that learning from safety events was consistently used to improve practice or reduce the risk of recurrence.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They supported continuity of care, including when people moved between different services.
The provider had systems to assess whether they could safely meet people’s needs before accepting care packages. The provider requested referral information and care plans before care started. The provider completed face-to-face assessments with people to understand their needs, ask further questions and identify whether staff could provide safe and appropriate care.
The provider demonstrated they had refused care packages where they could not safely meet people’s needs, or where there was not enough time to complete a thorough assessment. Feedback supported this. One relative told us the provider visited their family members home, explained the service and asked appropriate questions before care started. They said the start of the care package felt “safe and organised”. A professional also described the start of the package as safe, organised and well planned. The provider had arrangements to support continuity of care when people moved between services. Discharge information was checked, and relevant health professionals were contacted when further information was needed.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.
The provider had safeguarding policies and procedures in place. Staff had completed safeguarding training, and the provider used a training matrix to monitor training. Staff we spoke with understood how to identify and report safeguarding concerns. They were able to describe different types of abuse and knew concerns should be escalated to senior staff and external agencies where required.
The service was not supporting anyone who was subject to restrictions because of their capacity, such as a community Deprivation of Liberty Safeguards authorisation (DoLS) or court order. Therefore, we did not find evidence that people were being unlawfully restricted.
Staff demonstrated a good understanding of people’s communication needs, preferences, wishes and feelings. This was important because the service supported people with learning disabilities, including people who may communicate distress, discomfort or concern in different ways.
However, the provider needed to strengthen records to evidence how safeguarding concerns, actions and learning were consistently recorded and reviewed. This would help demonstrate that safeguarding systems were fully embedded and that learning from concerns was used to improve practice.
 

The provider did not always work well with people to understand and manage risks. Risk assessments were not always personalised, and people and relatives were not consistently involved in developing them. This meant the provider did not fully involve people, or those important to them, in decisions about how staff managed risks.
Staff did not always update care plans when people’s needs changed. This meant staff may not always have had accurate and current information to support people safely.
The provider did not consistently record positive risk-taking decisions, review risks with people or update care records following changes in people’s health or support needs. This reduced the provider’s ability to show they had involved people in managing risk.
We received mixed feedback on involving people to manage risks. While some people and their relatives told us staff managed risks well, others raised concerns about how the provider communicated what actions were taken when things went wrong and where this information was recorded. This showed the provider needed to improve how they documented and shared risk-related 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.
The provider assessed people’s home environments before care started. Arrangements were in place for staff to report environmental concerns to senior staff. We found the provider had systems to respond to concerns about people’s homes or equipment. Staff contacted senior leaders when they identified an unsafe environment. Senior staff then escalated concerns to relatives, relevant healthcare professionals, the local authority or other agencies where required.
The provider had a lone working policy in place. This supported staff safety when they worked alone in people’s homes.
Relatives and professionals gave positive feedback about how staff supported people safely outside the home. Relevant risk assessments were in place to guide staff when people accessed the community or took part in activities.
However, the provider needed to continue strengthening records to evidence how environmental risks were reviewed and how the service kept risk assessments up to date and accurate.
 

The provider did not always make sure staff were safely recruited, qualified, skilled and received effective support, supervision and development.
The provider had not fully completed recruitment files. This meant the provider could not demonstrate that they had completed all required safe recruitment checks before staff provided care. Staff supervisions and appraisals were not regularly documented. The provider could not demonstrate that staff received regular formal support, development or performance reviews.
The provider had evidence that they completed some spot checks or competency assessments, but these were not sufficiently robust or consistently recorded to show how the provider assured themselves that staff had the skills and knowledge to meet people’s needs safely.
The provider had systems to monitor staff training, and records showed staff had completed mandatory training. However, some mandatory training had expired, and the provider had not used the training matrix effectively to identify this and take timely action. This meant the provider could not fully demonstrate effective oversight of whether staff training remained current and relevant to people’s needs.
However, the provider planned staffing arrangements so there were enough staff to meet people’s needs. The service tried to match people with suitable staff and used more experienced staff to support less experienced staff where required.
People, relatives and professionals gave positive feedback about staff reliability and consistency. One person told us, “staff are reliable, arrive on time and have not missed any visits”. A relative said staff were “always on time” and described the care as “consistent”. However, positive feedback did not mitigate the provider’s responsibility to maintain safe recruitment records, supervision and competency oversight.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of infection spreading or demonstrate that they shared concerns with appropriate agencies promptly.
There were gaps in the provider’s infection prevention and control governance. The provider did not complete specific infection prevention and control [IPC] audits. There was no personal protective equipment [PPE] stock records, some staffs IPC training had expired, and spot checks had not been recorded. This meant the provider could not demonstrate effective oversight of IPC practice.
The provider had not maintained the records needed to show they monitored IPC practice effectively. The lack of audits, stock records, current training and recorded spot checks meant the provider could not evidence that staff followed safe IPC practice consistently.
However, the provider had basic IPC arrangements in place. Staff had access to PPE from head office. Staff were expected to use, PPE, regular handwashing routines and clinical waste bags when supporting people in the event of a contagious illness. Staff were expected to report infection risks to the registered manager, who would contact appropriate services where needed.
A staff member told us, “I know the manager would deal with any concerns relating to PPE if an issue occurred, we always have enough PPE and if we report that we need more, it is always provided in time” This showed staff had some confidence that the provider would respond to IPC-related concerns.
 

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. The provider could not always demonstrate effective medicines governance or oversight.
Although the provider told us medicines administration record [MAR] charts, refusals and stock issues were audited, they had not provided evidence of medicines audits that were completed effectively. We found MAR charts had not always been filled out incorrectly, with missing signatures and incorrect recording of dates.
Medicines errors were not always reported appropriately using the providers own policies and procedures. Pro re nata (PRN), medication taken on an as needed basis rather than a fixed schedule guidance was not always tailored to the individuals the service supported.
However, medicines responsibilities were recorded in people’s care plans. Staff who supported people with medicines had completed medicines training and competency checks.
One person gave positive feedback about medicines support and said, “since being with my carer my medicines are done much better, and I now don’t miss any medicines”. This showed the person felt their medicines support had improved since being with the service.