Archived: 23 Pierrepoint Road

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 regulations in relation to safe care and treatment and safeguarding people from abuse and improper treatment.

This service scored 44 (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’s systems for learning from incidents and things that went wrong had not always been effective. An external professional who worked closely with the service explained issues with poor practice were not resolved and staff had not learnt from these. They explained, “[There are issues] around communication. For example, verbal and written handovers between staff mean there are often mixed messages and different accounts of events from different members of staff.”

There had been several similar incidents which placed people at risk of harm. These included insufficient responses to medical emergencies and medicines errors.

The acting manager explained they were working with staff to try to address gaps in their knowledge and practice. They had introduced new guidance and enrolled staff on specific training to help improve their understanding about how to respond when people’s health deteriorated. This work was ongoing and changes had not been embedded at the time of our assessment.

The provider had systems for safe transitions and pathways. Everyone living at the service had lived there for many years. Staff created documents designed to share with external healthcare professionals if people needed to access other services or were admitted to hospital. These documents included key information about people’s communication and healthcare needs. Managers liaised with people’s relatives and external professionals to help plan safe transitions when people moved from the service.

People were not always safeguarded from restrictive practices. During our assessment, we observed staff repeatedly attempting to prevent a person from moving freely around the service by blocking their way. This practice had not been planned for or assessed as safe or appropriate. The person was not at risk and did not pose a risk to others. It was not clear why this restrictive intervention was being used.

People were not always protected from avoidable harm. Shortly before our visits to the service, there had been safeguarding concerns where people were placed at risk of harm. These included inappropriate interactions from staff, medicines mismanagement and unexplained injuries. The acting manager had alerted the local safeguarding team and discussed these with staff.

Whilst the provider, had introduced systems to help staff learn from these incidents, they were not able to provide assurances people were safe from further avoidable harm. Representatives of the local authority and healthcare partners told us concerns about poor practice had not been fully addressed.

Staff completed training to understand about safeguarding and were able to describe how to recognise and report abuse. The acting manager discussed how to recognise and report abuse with staff. There were suitable systems for supporting people to manage their finances and help to protect them from the risk of financial abuse.

The provider requested legal authorisations where the provider had identified restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these.

The provider did not always assess, monitor or mitigate risks to people’s safety and wellbeing. During a visit to the service, we identified cleaning products and medicines were not always safely stored. Care records indicated people were at risk because they did not understand the potential dangers connected to these items. The acting manager addressed these concerns when we explained what we had found.

Staff did not always follow best practice or guidance to keep people safe. Some people were at risk when eating and drinking. They had been assessed as requiring supervision and support. Staff did not ensure 1 person was seated correctly. The person kept twisting and moving in their chair whilst they were eating. This increased the risk of choking. Guidance from a specialist stated, “Supporting team members should encourage [person] to be sat upright (ideally at an angle of 90 degrees).” Staff did not redirect the person or ensure they were seated correctly. Staff supported another person with a drink. They did not look at the person whilst they were drinking and were distracted by looking elsewhere. This meant they could not ensure the person was drinking in a safe way.

Staff had assessed some risks to people’s safety based on information about their needs. There were plans to mitigate identified risks. However, the information was not always complete, accurate or up to date. The acting manager had identified gaps in these records and had started to update and improve these.

The environment was not always safe or suitable. The garden was overgrown and the path was uneven making it unsuitable for people with restricted mobility. Old furniture and rubbish which needed to be disposed of was stored in the garden. Some of the windows did not have working restrictors, meaning there was a risk the window could be opened wide, and people could fall from this. Some radiators had not been covered to help reduce the risks associated with hot surface temperatures. Areas of the building and furniture needed repairing, decorating and/or replacing. The acting manager had carried out a building risk assessment and had already identified hazards. They had requested support from the provider to address these. The acting manager sent us evidence of further work they requested following our visits to the service. The provider took immediate steps to improve safety, including equipping windows with restrictors.

The provider had made improvements to fire safety following a recent fire safety inspection. Further improvements were planned to fire doors. The provider had a system in place to help mitigate risks whilst waiting for the work to be completed.

There were enough staff to keep people safe and meet their needs. There were no staffing vacancies, and most staff members had worked at the service for several years. Staff knew people well. Staffing levels were calculated based on people’s assessed needs. Staff absences were generally covered by the existing staff team working extra shifts. This ensured people received consistent care from familiar staff.

There were procedures to ensure staff were suitable during recruitment. These included a range of checks. New staff completed inductions to the service and undertook essential training. All staff completed regular training updates. Managers assessed staff skills, competencies and knowledge following training. Staff were supported through regular supervision, meetings with managers and appraisals of their work.

Relatives told us there were enough staff. Their comments included, “There are enough staff, including at night and weekends”, “The staff are familiar faces” and “I think the staff seem to be well trained.”

Systems to prevent and control infection were not always followed. Areas of the building required deep cleaning to remove ingrained dirt and limescale. There was no toilet roll or hand soap in toilets and bathrooms. A relative explained they had found this to be the case when they visit as well. There were also no paper towels in some toilets. We observed staff wearing disposable gloves for multiple tasks without changing these in between. We discussed these findings with the acting manager who agreed to take action to address the concerns.

The provider had procedures relating to infection prevention and control. Staff undertook relevant training.

Medicines were not always managed in a safe way. We identified gaps in medicines administration records (MAR) where staff had not signed to state whether medicines were administered or not. There was no reason for this, and staff were unable to confirm people had received their medicines as prescribed.

We observed staff signing MAR before medicines was taken by the person (which contravened the provider’s policy). We witnessed a controlled drug being administered without a second member of staff signing as a witness. We saw medicines being left unattended on the dining room table despite people walking around the room freely. This placed people at risk of inadvertently taking or misplacing medicines.

We found a bottle of expired liquid medicine in the cupboard which was not isolated. There was a risk this could be administered. Staff were administering a medicine for 1 person without a record of this on the person’s MAR. Handwritten changes on MAR were not checked or double signed increasing the risk of errors.

Staff had not recorded or identified the risks associated with people’s medicines in care plans. For example, 1 person was prescribed a medicine that was subject to a national patient safety alert. This was not highlighted and there were no plans to ensure the risk was being managed. Another person was prescribed a time-sensitive medicine. However, the importance of timely administration was not highlighted on the MAR or care plan. There is a risk of delay to the medicine administration which could negatively affect this person’s symptoms and disease progression. Some people were prescribed PRN (as required) medicines. There was not always guidance in place to ensure staff understood how and when these needed to be administered.

Staff were not consistently checking the temperature of medicines storage to make sure this was a safe level. Equipment used for blood glucose monitoring was not calibrated in line with the manufacturer’s recommendations.

Controlled Drugs (CDs, medicines which require extra security) were stored appropriately.

This provider stored medicines in locked cupboards. There were appropriate risk assessments for medicines which were flammable, such as paraffin-containing emollients.