Collingswood House

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

The key question of safe was rated as good at our last assessment. At this assessment the rating has changed to requires improvement. People we spoke with felt safe and protected from the risk of harm and abuse. Systems were generally in place to keep people safe. There was a safeguarding policy, staff had safeguarding training, and they told us they would report any concerns they had. Staff supported people who had capacity to make decisions about risk. Risk assessments for these people were completed to promote independence and minimise risks to people and staff. However, the service had not adequately assessed the safety of people who did not have capacity to consent but were locked within their own homes. This failure put people at risk of harm and the service was in breach of regulation. Staff were not always being given adequate travel time between visits to ensure visits both began on time and were not ended early. Therefore, this was a failure by the service and a breach of regulation relating to how the service was being managed. The service ensured there were sufficient safely recruited staff to carry out visits, and they had received training to meet peoples’ needs. Service managers were working to create a positive learning culture at the service. At our previous assessment in January 2024 the service did not manage peoples’ medication effectively. The service had improved in this area and now effectively administered people’s medication where the service was commissioned to manage and administer people’s medication. The service and their partners in the health and social care system were working together in partnership. However, the service and commissioning Local Authority had not worked together to assess people at risk under the MCA.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

Managers in the service were not aware of the potential the Mental Capacity Act (MCA) 2005 might need to be applied with people using their service. Once they became aware during our assessment, they contacted the statutory health and social care professionals to ensure that review was undertaken to see whether the MCA might need to be applied.

Health and social care professionals had not contacted us with any concerns about the service.

When people had been discharged from hospital the service made sure the package was in place before the person returned to their home. The service did not always assess people's capacity to consent to decisions about their care when they started using the service in line with the service's policy and process.

All the people we spoke with said they felt safe with the staff from the service. However, some people were being locked in their own homes without assessment of the risk of doing this. These people were being put at risk.

We were told by managers of the service that some people who did not have mental capacity were being restricted within their own homes, and their relatives and visiting staff, could only gain access to their home by using a secure key box system. We fed back to the service we were concerned that none of these people had these restrictions assessed either for safety or under the Mental Capacity Act (MCA) 2005. Although staff and managers were having mandatory Safeguarding training, management of the service did not have the knowledge and skills to recognise the need for thorough risk assessment in these circumstances. Therefore, the people using the service were not being adequately protected from the risk of harm.

We found through our enquiries at the service, that a number of people were being restricted within their own homes when they were likely to not have capacity to agree to this restriction. The day after our second visit we requested that the service identify all of those who might be included within the need to be assessed under the MCA, which they did. This information was then submitted by the service to Plymouth Local Authority, to ensure that as soon as possible, everyone’s circumstances could be assessed by the Local Authority to ensure that they were safe, or to take immediate action if they were not. At our last assessment of the service in January 2024 we had identified to the service that they did not have adequate knowledge of the MCA and its application in community settings. The service had obtained some training for office staff on how to carry out a capacity assessment but had failed to obtain knowledge and skills on the MCA. The service had Safeguarding policies and procedures in place, but these did not cover the MCA. As we left the service at the end of our second visit the managers said that MCA Policies and Procedures would immediately be written. These issues contributed to a breach of regulation.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us staffing was good, one person said, “I trust them. They help me get ready in the morning and do some household jobs, get lunch for me and then get me ready for bed – one (staff) can be a bit late sometimes." However some people were concerned about staff sometimes being late, not staying the full amount of time as required, and staff appearing rushed.

We heard from some staff there was a practice of rostering visits ‘back to back’ without travel time allocated between visits. Staff also told us there was sometimes inadequate time between visits. One staff member wrote, "I am constantly given back to back care calls with no time to get between clients, I don't think this is safe, I am constantly rushing my visits, which allows me to leave the client early, to get to the next one. I also don't think this is fair on our clients, they shouldn't be rushed, and they shouldn't be getting calls for less time than they pay for. But I have no choice, if I do the full time, I then get angry service users on why I'm late."

We saw records of the times of arrival and departure of care staff to people’s homes. On our first visit these were largely inaccurate. On our second visit we noted a significant improvement in keeping these records accurately. We also saw visits were being cut short. We were told by managers that people were always in agreement with staff leaving early. Staff told us they were required to use the service’s IT App on their personal mobile phones and often did not have a signal while carrying out their visits. Therefore, they could not reliably or accurately send arrival and departure times to be recorded on the service’s IT system. The lack of this data in an accurate form, affected the ability of the service to tell whether the commissioned time period of each visit had been delivered. These issues contributed to a breach of regulation.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us their medication was well handled by the service, when it was necessary for the service to take responsibility for administration.

We heard from the managers and staff that they took great care with the handling and administration of people’s medicines, where it was necessary for them to take this responsibility.

We saw records of medication administration which were thorough and clear. Training for staff on medication administration had been greatly improved since our last assessment in January 2024, and the previously identified need for additional training and clear record keeping had been addressed.