Marlow

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 regulation in relation to the staffing of the service.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Although incidents were recorded, appropriate learning did not always take place. For example, one person had a prolonged period of anxiety that required many members of staff to resolve but no steps were taken to ensure this was mitigated in the future.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. For example, one person lived with epilepsy which was managed by specific medication. Not all members of staff followed or correctly understood the person’s written epilepsy protocol for guidance about what to do when this person had a seizure. This meant that there was a higher risk of this person not always getting their medication at the right time. We spoke with managers, and they reviewed the particular protocol to improve clarity for staff.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They did not always share concerns quickly and appropriately. Staff and leader’s we spoke to, knew of the signs of abuse which needed to be reported as safeguarding. However, the appropriate people were not always told of specific incidents. For example, one person needed to attend hospital to check for a head injury after a period of self-injury. This person was examined and returned to the service, but the local authority and CQC were not notified that this person attended hospital because of a possible serious injury. The provider did retrospectively notify the relevant people following this assessment.

The provider did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

There had been a number of concerns raised about the managers and staff lacking the skills and knowledge to identify and manage risks. This was mostly in relation to people’s complex health needs. These had previously resulted in incidents of harm. The provider had made changes to the management arrangements and improved staff training with considerable support from the health professionals and local authority teams.

Staff knowledge and guidance had improved; however, this was not embedded, and staff were not always following the updated guidance, which demonstrated gaps in understanding of the risk. Areas including positive support and communication had not been prioritised. We raised this with senior managers who assured us they would work with people around risks posed by behaviours of concern.

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

There was not always enough qualified, skilled, and experienced staff. Staff did not always receive effective support, supervision, and development. Staff did not always work together well to provide safe care that met people’s individual needs. The service was in breach of legal regulation in relation to the staffing of the service.

People did not always receive their 1:1 support. For example, a relative told us on 2 occasions in recent weeks only 1 member of staff was available for 3 people, all of whom should have had their own 1:1 staff member. The manager confirmed this was a combination of staff absence and staff deployment issues. Although staff had received training around supporting autistic people, this was not always reflected in their practice. For example, supporting a person to put their outdoor shoes on then having them wait before going out was confusing and distressing for the person, their relative told us. Speaking to staff it was clear some did not understand how to support autistic people in practice, we did not see any use of augmented communication tools or use of intensive interaction strategies or sensory activities such as water play in relation to an autistic person. However, another relative also told us their loved one had been at the service for many years and, “They have never had a problem with the staff, they know [loved one] very well.”

Work was ongoing regarding managing staffing shortfalls and to reduce agency staff use in recent weeks. Some training had been undertaken for shortfalls identified by visiting health professionals and staff we spoke to were knowledgeable in these areas. The consistency of staffing skills was variable, with some staff providing good support while others lacked the skills needed to support people with complex needs. Managers showed us the steps they were taking to support staff to gain competency in their roles. This was not yey embedded and could not demonstrate sustainability.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They now involved people in planning, including when changes happened. Two medicine errors were reported to us during the assessment period, both were picked up quickly and appropriately addressed by the current manager. Improvements in practices still needed to be fully embedded for example , as required medicine (PRN) protocols should clearly reflect the actions to be taken prior to administering for people who have them to support episodes of heightened anxiety. While protocols stated refer to the plan, this meant staff would need to consult a different document at a time where they needed to be focused on the situation and person they were supporting. This was raised and the manager addressed immediately.

We observed trained and assessed as competent staff supporting people to take their medicines in ways which best suited them. Staff were seen to talk to the person and ask if they were happy/ready to take their medicines in a friendly and respectful way.