78 Stubbington Lane

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 inadequate. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements had been made following our previous inspection. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events.

Lessons were learnt to continually identify and embed good practice. Staff knew what incidents to report and how to report them. The manager shared learning with staff through staff communication channels and team meetings.

The manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

The service 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.

The provider had a robust admissions policy in place. The manager was able to explain the process including assessing people to establish suitability and compatibility prior to moving in, registering with a GP and ensuring enough medicines were available at the point of transfer.

People were consistently supported when they were distressed and there was a focus on planning for a good day and understanding what had caused people distress so positive changes could happen.

Improvements had been made following our previous inspection. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The service shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies. Where restrictive practices were in place Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions placed on people to keep them safe.

The service did not always work well with people to understand and manage risks. We reviewed people’s care plan and daily notes. We saw evidence of people making unwise decisions relating to their food consumption. Healthcare professionals had been involved in supporting with this. Professional’s told us they were concerned about how the provider was managing these nutritional concerns, they also told us they were concerned this had been an ongoing issue. Following our assessment, the provider has shared with us evidence of a professional closing this person’s case, as they were now satisfied with the improvements made.

There had been several changes of manager in a short space of time which had meant there was a lack of continuity. The new manager told us they were committed to working with professionals to ensure the best outcomes for people.

People were assessed for risks of falls, risk of choking and risks when using the kitchen. When risk had been identified staff followed actions to keep people safe such as providing additional equipment and the appropriate level of support. The manager gave us an example where a person had wanted to go swimming. There were several risks relating to this, but it was agreed the benefits of going swimming outweighed the risks. Risk assessments were devised, and the activity was successful. This has now become part of the person’s weekly routine.

The service 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 and fire safety risk assessments were completed and checks made of equipment to ensure it was safe to use. Any concerns with equipment were reported to the management team or appropriate person for further action.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

We received mixed feedback from relatives. Some relatives told us they found some staff more knowledgeable than others.

One staff member told us, “Obviously it can be difficult in those moments when a staff member phones in sick but generally there are enough staff to support people to go out and support people who want to stay home.”

The manager had a training matrix in place which evidenced most staff had completed all of their statutory and mandatory training and competency assessments to ensure they were able to meet people's individual needs. Where staff had not completed training, they were booked on to a session. The provider followed safe recruitment practices.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We observed some bedrooms with paint missing on areas of the walls and stained carpets. We observed woodwork which was scuffed and chipped. We spoke with the provider about this. During our third on-site visit, we observed a maintenance team completing the redecoration work. The manager told us, they would ensure the carpets were cleaned and this would be added to the cleaning schedule.

In the kitchen, we found food was not always managed in accordance with good practice increasing the risk of contamination. We spoke with the provider about our concerns, they removed the food and told us they would put robust systems in place to mitigate the risk of this happening again.

Relatives told us the home was clean, and this was an area of improvement. We observed the home was mostly clean.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities, and preferences. We reviewed 1 person’s medication administration record (MAR) and observed they were administered paracetamol most days over a 2 month period. The provider had sought advice from a medical professional. They were advised, staff should offer a cold flannel or ice pack in the first instance to see if this reduced the need for paracetamol. We found no evidence this was happening, and none of the staff members we asked about this, told us this was the procedure they followed. Improvements had been made following our previous inspection.

Staff received medication training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines. Staff told us they felt well trained and confident to support people to receive their medicines safely.

The manager told us, during people’s annual health reviews, stopping over medication of people with a learning disability and/or autism (STOMP) plans were reviewed.