Essex Care Consortium - Colchester

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

At our last inspection we rated this key question inadequate. At this inspection the rating has improved 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. We looked at all the quality statements for Safe at this assessment. We found there has been an improvement in the service since the last inspection. Overall, the service was safe, but improvements were needed to ensure safety was given top priority. You can find more details of our concerns in the evidence categories below. Systems to protect people from avoidable harm or abuse and keep them safe had improved. Lessons had been learned from previous safety incidents, however managing risk was still not always seen a as priority, by the provider. Restrictive practices were not always being carried out in accordance with legislation, and best practice. Arrangements to monitor the safety and upkeep of the premises, including fire safety were not always effective. Improvements were needed to manage people’s medicines and ensure the premises was clean and hygienic. There were enough suitable staff with the right competencies, knowledge, and attitude needed to keep people safe and meet their needs.

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 service had learned from incidents and made changes to improve staff understanding and delivery of care, and to keep people safe. Lessons had been learned following choking incidents in the service. Following a recent incident changes to people’s care were made to prevent similar events happening again. However, safety concerns were still not consistently identified or addressed quickly enough which continued to place people at risk of harm.

Staff told us lessons had been learned from previous choking events that had put people at risk of harm, or that had caused them harm. They told us, input from SaLT and training in dysphagia and emergency first aid had improved their confidence and understanding on how to support people with swallowing difficulties to eat and drink safely and respond to emergencies. Staff confirmed they could raise concerns with the senior managers and were confident their concerns or suggestions about people’s safety were listened to and acted on.

Although, incidents and safeguarding concerns had been investigated, the quality of investigations were not always robust to ascertain the root cause of why things went wrong. Where actions had been taken to prevent similar events occurring this had not always been clearly documented, or reviewed to ensure improvements were embedded and sustained.

People’s care and support was planned for and organised with them, together with their next of kin, social workers and other health professionals. This meant there was a joined-up approach to safety and continuity of care. Two people, recently moved to the service told us they were happy living at the service and felt supported by staff.

Staff confirmed they were fully informed about people’s needs as they moved into the service. They had access to information about the support people needed, risks to be aware of, and how these were to be managed to protect the safety of the individual and others. Staff showed us systems used to share information about people to ensure consistency in their care, including a group chat on a mobile device.

Systems were in place to proactively consider, assess and manage risks to people when moving between services. People’s records confirmed their care, and support was planned and organised with partners. Their care records reflected recommendations made by social workers and health professionals which were followed by staff at the service. This ensured people received safe and continuous care.

People told us they felt safe. Managers worked well with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff spoke knowledgably about people’s needs, and how to keep people safe. They had a good understanding about safeguarding, when and how to report concerns about people’s safety. Where video monitors were used to detect and monitor people’s seizure activity managers confirmed this has now been included in the persons deprivation of liberty safeguards (DoLS) assessment authorising the deprivation of their human right to privacy. Review of people’s records confirmed this, with controls in place to ensure monitors were stored in the office, with the door closed and only reviewed by staff on duty.

Staff demonstrated a commitment to keeping people safe. We observed people freely moving around their home, at ease with the staff supporting them. People were engaged in activities with arrangements in place to minimise the risk of harm and keep them safe. Staff worked well with people, providing reassurance when they expressed worries or concerns about their safety.

Systems and processes to safeguard people from the risk of abuse had improved. Managers were aware of their responsibilities to report concerns to the local authority safeguarding team. For example, they had worked well with the local authority to respond to anonymous concerns raised about the lack of induction, support and direction on night duty and used outcomes as an opportunity to change practice. However, oversight of incidents, accidents and safeguarding concerns needed to improve to ensure themes, and or trends were identified, and acted on to protect people from further incidents of abuse, or neglect. The registered manager told us they have since implemented new processes to ensure better oversight and analysis of incidents.

Where people communicated their needs, emotions or distress through behaviours this was not always being managed in the most positive way, or in line with legislation, and best practice guidance. Incidents were not always learnt from to reduce the cause of people’s distress.

Records showed, short periods of seclusion had been authorised under DoLS for people’s safety at times of distressed behaviours. Managers told us they were unaware this practice needed to be carried out in line with Department of Health and Social Care (DHSC) guidance for reducing restrictive interventions legislation, and a clear record kept. They confirmed no policy had been developed to guide staff on the use of seclusion. Staff had a good understanding about managing risk to people, by thinking broadly and described “having to be on their toes completing quick on the spot assessments”, to respond to immediate risks where people liked to be involved in activities, such as cooking and cleaning.

We saw positive interactions between people and staff. Staff demonstrated a real empathy for the people in their care. Where people were non-verbal, we saw they were supported to use picture cards to communicate with staff, including their choice of meals, snacks and drinks in line with their dietary needs.

Systems to record, manage and report concerns about incidents and risk to people’s safety were not consistently identifying or addressing outcomes for people a positive way. Where people communicated their needs, emotions or distress through behaviours staff completed incident packs which contained a lot of duplicated and inconsistent information. Managers were unable to demonstrate how they analysed information to identify the potential cause of the behaviour, or what the person’s behaviour was communicating. Establishing patterns and putting measures in place may prevent incidents happening again and reduce the need to administer sedative medicines to manage behaviours, in line with stopping over medication of people with a learning disability and autistic people (STOMP). The registered manager has since confirmed an incident log has been implemented and is analysed at the end of each month to look for trends to prevent incidents reoccurring. Improvements had been made to assess and manage the risk of choking. All people with swallowing difficulties had been reviewed by SaLT to ensure up to date guidance was in place about their dietary needs to minimise risk choking. Care plans clearly reflected what the person could or could not eat and included instructions for staff on how to safely prepare peoples’ foods in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI). IDDSI is the global standard to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures.

People were not always cared for in a safe environment. Arrangements to monitor the safety and upkeep of the premises were not always effective to support the delivery of safe care.

The nominated individual (NI) responsible for supervising the management of the service on behalf of the provider was new in post. They told us, the recent changes at Director, NI and general business managers meant some issues requiring action to ensure the safety of the premises had been overlooked. Although they had taken prompt action to address the safety issues we raised, they acknowledged improvements were needed to ensure better oversight of environmental risks.

Essex Care Consortium – Colchester is made up of 2 main houses, Birch and Cedar, with additional chalets within the grounds. People had exclusive possession of their own rooms. Internally the premises were well designed for the people living there. However, aspects of safety had not always been considered, such as ensuring wardrobes were secured to the wall to prevent these being pulled forward, which placed people at risk of harm. Birch House was not as nicely decorated as Cedar. The provider told us the house was scheduled for refurbishment.

Arrangements in place to check the safety and upkeep of the premises were not effective. Review of records designed to detect and control potential risks to people using the service, had not always been used to ensure the care environment was safe. This meant safety concerns were not consistently identified or addressed quickly enough. For example, the risk and potential harm to people from unsecured wardrobes had not been assessed. A monthly maintenance plan reflected routine safety checks were taking place; however, we found outstanding actions in the fire risk assessment from 12/12/2022, repeated in the most recent assessment 05/11/2024. There was no action plan to address actions with robust timescales for completion. Personal emergency evacuation plans (PEEP’s) needed improvements to ensure these were legible and contained details about the risk to people prescribed flammable emollients in the event of a fire. The provider has since taken immediate action to update PEEPs, ensure wardrobes have been secured and completed the actions in the fire risk assessment, however they had failed to identify these risks to people’s safety.

People were supported by enough qualified, skilled and experienced staff, including additional staff funded to support people on a 1-1, or 2-1 basis to access the community, including day care facilities.

Staff told us the skill mix of staff had improved with the recruitment of more permanent staff, with less reliance on agency. Although some agency staff were still used, these were regular agency staff who knew the people using the service well. Agency staff told us they were included in training, and meetings which made them feel included and ensured they had the support needed to deliver safe care. Staff including new staff confirmed they had completed a robust induction, and a range of training which ensured they had the skills, and knowledge to meet people’s needs.

Most people using the service were allocated staff on a 1-1 basis. During our visits we saw there were enough competent staff available to ensure people were receiving the right care that met their needs and kept them safe. We saw people were provided with the encouragement and practical help they needed to eat well and enjoy daily activities on site and in the wider community.

The NI and registered manager told us, they reviewed the complexity of people’s needs and levels of dependency on a regular basis. However, they could not demonstrate how they continually assessed staffing levels to ensure they were right as new people were admitted to the service, or as people’s needs changed. Recruitment processes were not robust to ensure staff were safely recruited, suitably experienced, competent and able to carry out their role. Recruitment documents, including those staff on sponsorship were not easily located to ensure safe and robust recruitment checks were in place.

People were not always protected from the risk of infection due to shortfalls in cleanliness and hygiene.

Staff told us, they had access to adequate supplies of personal protective equipment (PPE) and had completed infection prevention and control training (IPC). They were aware of their roles and responsibilities to keep the premises clean and hygienic and referred to a list of ‘jobs to be done whilst cleaning’. However, we found staff did not consistently apply good infection control practices, areas of cleaning were being missed, which increased the risk of bacteria developing, and spreading infection.

We visited both shared houses, Cedar and Birch and found the premises, including kitchens en-suite facilities, communal toilets, bath and shower rooms were not as clean as they could be to prevent the spread of infection. For example, we found mould growing underneath nonslip shower mats, where these had not been lifted. The underneath of shower chairs had not been cleaned properly and toilet brushes were sitting in fluid providing a breeding place for potential bacteria to grow, all of which increased the risk of people acquiring infections and associated implications to their health.

The provider did not have robust systems in place to effectively identify the risk of infection. Infection control measures needed to improve to ensure the service was clean and hygienic in line with current and relevant national guidance. The providers infection control policy did not align with DHSC guidance for the prevention and control of infection in adult social care. The policy required updating to clearly reflect systems in place for the prevention, governance and leadership to manage risk of infection. The policy also referred to a different service, not associated with the provider, and was therefore not relevant to Essex Care Consortium – Colchester.

People were provided with information about their medicines and why they needed them. This was provided in easy read formats to help them understand how and when they should take their medicine. Staff took time to explain and provide reassurance to people when administering medicines, however we found people were not always receiving their medicines as prescribed by their GP. This had the potential to affect people’s health or place them at risk of harm.

Staff told us they had received medicines training; and had their competency to administer medicines checked on a regular basis. However, they were not following the providers medication policy when ordering and storing medicines. Prescribed topical creams and lotions had not been dated when opened to ensure these remained effective and they were used with given timescales. Staff that we spoke with were not clear about the process when opening new bottles, and or boxes of medicines. Staff could not explain why the medicine cupboard in Cedar was overstocked, with up to 5 months’ supply of creams and lotions for each person. The shelves were untidy, making it difficult for staff to see what stock was held to ensure only items needed were ordered. Staff were clear medicines prescribed to reduce anxiety and distress, were only ever given as a last resort, in line with people’s positive behaviour support plans.

The provider did not have effective arrangements in place for the safe management of people’s medicines. Weekly audits had not identified medicines were not always stored, administered and managed safely. Staff were not always clear about their responsibilities and roles in relation to use and storage of medicines. We found issues with medicine stock levels and found some controlled drugs which were not stored or being administered in line with prescriber instructions and best practice guidelines. The provider was responsive and took immediate action to resolve issues found by inspectors. A senior manager has been designated to oversee medicines, including the re-ordering, storing and disposing of medication.