Adrian O'Brien Rachel Amiee O'Brien - 122 Scorer Street

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

We assessed all 8 quality statements in the safe key question. We found 1 breach of legal regulation relating to staffing. There were not enough staff to safely support people. Staff completed training in line with their role, however training was not always effective in ensuring staff knew how to assess risk and understand how to support people when they were distressed. Incidents were not always safely managed, and lessons were not learnt to reduce the risk of reoccurrence to improve people’s quality of life. People were supported to understand safeguarding and how to keep themselves safe. Staff understood their responsibility to safeguard people and knew how to raise concerns.

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.

People told us they felt safe and well supported. Despite what people told us, we found incidents were not always well managed with minimal learning to reduce the risk of incidents happening again.

Staff told us they were debriefed after incidents but were unable to tell us where these were documented. They told us they had discussions following incidents with the people and staff involved to learn lessons and improve outcomes for people in the future. Despite what staff told us, we found incidents were mainly managed with police involvement with minimal evidence that incidents had been analysed to identify learning or prevent reoccurrence.

Incidents were well documented to show what had happened and what actions staff had taken. However, there was minimal evidence of processes in place where incidents were analysed and discussed with staff involved to support improvements and good outcomes for people.

People told us they were well supported when they moved into the service. They told us they had visited the service before moving in and had been involved in the decision to live there.

Staff told us they supported people to move in and feel settled in their new home by helping with clothes and furniture shopping when needed. A staff member told us about a positive outcome for a person who had moved on from the service due to the support they had received and how they had successfully supported them to transition to their new home. The registered manager told us because they were a small home they had to ensure that people were compatible. They told us they arranged visits so people could meet and then asked people who lived at the service if they were happy when someone was looking to move in.

The service worked collaboratively with health and social care professionals, although not all information had been shared with external services when there were safety concerns. For example, when there were not enough staff to safely support people, this had not been reported.

Assessments were completed before people moved into the home. However, information in people’s care records was not up to date and the most relevant information was not always included. This put people at risk if information was needing to be shared between services. Regular reviews were not carried out to ensure they were meeting people’s needs, and the placement remained suitable for them. We found the service was unable to meet a person’s needs, however this had not been managed effectively to ensure risks were managed and actions were taken to support good outcomes for the people they supported.

People told us they felt safe and were well supported by staff. A relative told us they believed their family member was safe. Despite what people told us, we found staff were sometimes calling the police to manage incidents and a person’s distress was regularly impacting on other people using the service.

Staff had a good understanding of their responsibilities to keep people safe. They told us how they would raise concerns and who they would report them to. Staff had received training in safeguarding which was up to date. The registered manager was unable to explain their process on how they would manage concerns. Although there had been no concerns raised, there was no evidence that systems were in place to manage them safely and effectively to ensure all relevant people were informed and referrals were made.

People we observed were relaxed in their home and were seen to be positively interacting with staff who supported them.

The provider did not have a clear system to record concerns and when asked, information was not easily available to view. The provider had a safeguarding policy that outlined procedures staff were to follow if they had concerns. Accessible information for how people could raise concerns or make a complaint was seen on a person’s pin board. No one was under a deprivation of liberty safeguard authorisation at the time of the assessment as we were told people had the mental capacity to make their own decisions. However, decisions were being made in people’s best interest as they were unable to understand the risks. For example, a person’s placement was being discussed without their knowledge or consent.

A person told us they were able to make decisions and were able to get out and about sometimes. Another person was accessing the community regularly and there was evidence the provider was supporting people to take some positive risks. Despite what people told us, we found staff were not always competent in responding when people were distressed which put people and staff at risk.

Staff told us how they empowered people to access opportunities. For example, they supported someone on holiday who had not had the chance to do that before. Staff told us they supported people to take positive risks by discussing the risks and helping them understand the information so they could make balanced decisions for example, when a person wanted a body piercing, staff discussed the risks with the person so they could make an informed choice. Despite what staff told us, we found risks weren’t always assessed and emerging risks were not always responded to appropriately.

Risks to people were not always managed in ways that supported people to be empowered to make their own choices. For example, when a person became anxious and needed to go out to manage this, it was only possible if another person that did not choose to go out, came with them. This was due to staff not feeling confident to safely manage risks outside of the home without the support of another staff member. This meant people were inadvertently impacted by other people’s distress, which potentially put them at risk if the other person’s anxiety was to escalate.

Guidance to support staff when people showed distress did not contain all the relevant information. Risk assessments had not always been carried out when risks had been identified, for example, when a person’s skin integrity was at risk of damage this had not been assessed and appropriate guidance was not in the care plan for staff to follow. This put people at risk of unsafe support. Following feedback, the provider updated the care plan to include guidance for staff. Risks relating to people when they were distressed had not been assessed and guidance for staff on how they were to support the person when distressed had not been reviewed to ensure it remained relevant and effective. This meant staff were inconsistently supporting people which put people and staff at risk. Furthermore, we were told a person would be at risk of self-harm, however this had not been risk assessed and there was no information relating to this found in their records.

People told us they thought the home was good and they liked their bedroom. A person told us they liked the service when they visited and had chosen to live there.

The registered manager told us they were responsible for maintaining the house. They had good knowledge of fire safety and other safety checks to ensure the environment was safe. Staff told us how they supported people to understand fire safety and regularly carried out fire drills to make sure they knew what to do in an emergency.

The environment was seen to be safe and well maintained.

Systems were in place to ensure the environment was safe. Audits of the environment included building and equipment checks. The registered manager showed us safety certificates which were routinely carried out.

A person told us staff supported them well, however, it was not clear if people understood whether they were receiving appropriate support. A relative told us they knew of recent staff sickness that had impacted on the service and believed there needed to be a better balance as it was such a small service.

A staff member explained they had been working additional hours as there had been some unexpected staff sickness and a staff member had resigned. After receiving feedback from us about the unsafe staffing levels, the registered manager introduced some agency staff. However, staff told us they did not feel comfortable leaving agency staff alone as they did not want to put people or staff at risk. This meant they had to continue working day and night shifts to support agency staff if required. The registered manager told us they knew the current staffing arrangements were not ideal, however the staff shortage had been unexpected, and they were managing it as safely as they could. Despite this, the staffing shortage had been going on for several weeks and actions had not been taken to improve the situation and make the staffing levels safe. Only following feedback from an inspector, were additional staff sourced. We could not be assured appropriate measures would have been taken if we had not visited the service.

Staff were seen to be supporting people as best they could to get out and about when they wanted to. However, staff were not always confident in supporting a person outside of the home without another staff present which impacted on the other person living at the service.

Recruitment checks were carried out to ensure staff were suitable to work at that type of service. However, the provider had not gained full employment history of staff to confirm their suitability for the role. People were not supported by enough trained and skilled staff. Due to unforeseen circumstances, there were not enough staff to safely support people. A contingency plan for if the service was to become short staffed was in place, however the registered manager had not implemented any of the actions to address the staffing situation. Following feedback, the registered manager recruited some agency staff, although this was not effective as both managers were still required to support people before agency staff could be safely introduced to people and the service. Staff had completed mandatory training and it was in date; however, training was not effective as staff were not always confident in supporting people when they were distressed. This put people and staff at risk of potential injuries and furthermore there was a risk incidents could escalate into more dangerous situations. Supervisions were not regularly completed and were not of good quality to ensure staff were well supported and any areas for development were identified and discussed. However, because of how small the home was, staff were regularly communicating with each other and the registered manager.

People or their relatives did not raise any concerns about the cleanliness of the home.

The registered manager told us they had cleaning schedules in place to ensure the home was clean and tidy. Staff had completed training in infection prevention and control and understood their responsibilities in keeping people safe.

The home was an adapted older building. We found the home to be clean and the communal areas were tidy. There were stocks of personal protective equipment to ensure safe and hygienic practice.

Regular audits were carried out to ensure the home remained clean. The provider had an infection control policy to support compliance with regulations and keep people and staff safe.

People or their relatives did not raise any concerns around the management of medicines. Despite this, we found some concerns relating to the safe management of medicines and the systems and processes in place to ensure safe and effective administration of people’s medicines.

Staff told us they supported people to manage their medicines safely. Staff had completed training in administering medicine, however the registered manager did not complete competency checks to ensure staff were competent and confident following their training. The registered manager told us they were implementing new systems which would include staff competency checks. Staff told us there were always medicine trained staff available including at night in case a person required ‘as required’ (PRN) medicine.

Systems were in place to manage the administration of medicine. We found some gaps in the medication administration record (MAR); however, the balance of medicines was correct, and the registered manager confirmed staff had forgotten to sign after dispensing the medicine. Systems were not in place to record when medicines had been returned to the pharmacy. This meant there was no audit trail to evidence medicines had been safely and appropriately disposed of. Protocols were in place when people had PRN medicines to guide staff on how these were to be safely administered. However, systems were not in place to monitor the use and effectiveness of PRN medicines. This would have been particularly important in monitoring PRN medicine offered when people were distressed to ensure people were not controlled by excessive and inappropriate use of medicines. There was no evidence the provider implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both). Care plans did not include information on how people liked their medicine to be administered. Furthermore, a person’s plan to guide staff on how to prevent their distress from escalating did not include information about their PRN medicine. This meant medicine to help people when they were distressed may not have been offered when required due to that information not being appropriately recorded. However, at the time of the assessment, the service was minimally staffed so all staff knew about the person’s PRN medicine which we could see in the records was being offered.