42 Twyford Gardens

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 requires improvement. At this assessment the rating has remained 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 provider was previously in breach of the legal regulation in relation to safeguarding. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to Staffing. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

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.

People's feedback was mixed regarding feeling their concerns would be listened to, one person told us “When I was worried about eating safely, I told them and they supported me to see a health care professional, but I have told them I don't feel safe since a new person moved in and I'm not sure they are taking it seriously.” With the persons consent we raised their concern with senior management who responded,implementing immediate quality oversight for the initial assessment process including reassessing a person's needs, to ensure they could be safely met, alongside speaking to people to gain their views. As a result, the provider identified they could not meet a person's support needs safely who subsequently left the service before our assessment process was completed. Following this action people expressed they were satisfied with the outcome.

The provider had systems in place to report safety concerns, staff knew how to use these systems and felt confident raising concerns, staff told us, “Managers would have a discussion with us after an incident, we spoke about what went wrong and how to improve next time.” Documents supported this with details of staff receiving debriefs following an incident to promote learning. We saw examples in care and support documents, where lessons had been learnt to improve people's safety which included obtaining specialist equipment to support a person following a fall.

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 from partners was not always explored in depth and used to ensure there were safe admissions to the home. For example, a person moved into the service with an external assessment that highlighted their care and support needs. Subsequent support plans did not effectively identify how these needs will be met, this resulted in people’s anxiety not being effectively supported which then had a further negative effect on other people’s experience living at the service. Support staff did not have the information they needed with clear guidance to safely fulfil their roles, for example people’s specific conditions were not fully understood regarding their experience of pain, with clear details around identifying when this is occurring and guidance on how to support them.

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. The provider did not always share concerns quickly and appropriately.

During the assessment we identified practice which fell outside of the providers policy in relation to supporting people to manage their money. For example, the sharing of pin numbers, whilst there was no negative impact found the potential risk of financial abuse was significant. This was raised with senior management who took immediate steps to report and mitigate the risks.

People told us things had changed since the most recent person moved in and they now felt unsafe. One person said when describing how they felt about their safety, “I don’t feel safe here anymore, what if I get hurt.” Following our visit robust action was taken by the provider who worked with the person’s local authority to find a more suitable place for them to live.

The manager had raised safeguarding concerns with the local authority but had not always submitted a statutory notification to CQC about an allegation of abuse in line with their regulatory responsibility. At the assessment this was clarified with senior management and relevant notifications were retrospectively submitted to CQC.

Staff told us they had training about safeguarding and demonstrated a working knowledge, and they told us they had been raising concerns around people feeling unsafe.

People were safeguarded to ensure that they understood their rights and protected against discrimination under the Mental Capacity Act 2005. The provider undertook decision specific mental capacity assessments to determine people’s capacity to make specific decisions about their care. The MCA promotes safeguarding decision making by empowering people to make decisions for themselves wherever possible, and by protecting people who lack capacity by providing a flexible framework that places them at the heart of the decision-making process.

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.

Risk assessments which should provide staff with the detail they need to support people did not always reflect people’s current support needs, for example despite being reviewed frequently details around pressure care support contained out of date information referencing equipment no longer being used and lacked information around current support being provided. However, staff knew the support needs of people around mobility and pressure care and the support was consistent with their needs.

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

Staff knew how to report maintenance issues which was reflected in the condition of the service, leaders had considered environmental risks to people and had plans in place to reduce these risks with clear guidance for staff to follow. Checks were in place to ensure essential equipment such as hoists worked as they should, and staff were involved in these checks. The provider had systems to effectively audit the service’s compliance with health and safety, with areas of noncompliance addressed where identified and maintenance requests actioned in a timely manner. The provider was up to date with safety compliance requirements. The service had been adapted with ramps at the front and rear of the property to facilitate wheelchair users to gain access to the garden. Each person had access to their own ensuite which was also accessible to wheelchair users.

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

Staffing levels remained the same following a new person moving into the service, this impacted on people's experience. One person said, “I need two staff for transfers so if another person goes out then I have to wait to change position” The provider responded to concerns raised by adjusting staffing levels. We observed staff struggling to communicate and support a person, the staff had received training in their specific condition, but this training was not always effective which impacted on the persons wellbeing. One staff member said, “I had an induction and received training before I started, e-learning and face to face. I did shadow shifts for 2 weeks before giving care alone.” Following training staff had their competency checked to ensure they had understood the learning, for example around administering medication. One staff member said, “I received training, then after training my manager checked my practice before I could give medication alone.” People told us their experience was different before another person moved into the service and the staff were able to meet their support needs until this point. One person said when describing the staff, “I know them well [ staff name] is really good but they are all nice, I get offered choice about what I want to do and my support including what I want to eat, they also speak to me kindly.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The building was clean and well maintained. Staff had access to personal protective equipment such as gloves and aprons and were aware when to use them. A cleaning schedule was in place for staff to follow and people were encouraged to develop their independence by taking part in maintaining their environment.

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.

Medicines were stored appropriately and administered by staff trained to do so. People told us they received their medicines in a way which suited them. Staff were seen to be both considerate and informative when supporting people with medicines. Records were clear and stocks checked regularly.