8 Acres

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

Breaches of the regulations in relation to safe care and treatment, including medicines management, infection prevention control and cleanliness, protecting people from harm and abuse, and ensuring sufficient numbers of suitably trained staff were identified, impacting on the standards of care and support people received.

People were not living in a clean, well maintained care environment. The service was not following safeguarding reporting processes to protect people from the risk of harm, and not reporting to external agencies including the police where applicable. There was not always enough staff shift to meet people's assessed needs and risks particularly at nighttime. The provider needed to make improvements to the overall running of the service to ensure people's safety and welfare was maintained.

This service scored 34 (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.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not being protected from the risk of harm, abuse and improper treatment, with evidence of closed cultures within the service, resulting in external professionals including CQC not being informed when people were involved in safeguarding incidents.

People’s equality, diversity and human rights were not consistently upheld, with people’s age and life experiences not being respected in the way they were treated and spoken to by staff.

Staff and leaders were not encouraged by the provider to report safeguarding concerns to external professionals, to maintain people’s safety and welfare.

Whilst staff were able to tell us how to report safeguarding concerns, our findings demonstrated this information was not being acted on by the registered manager or provider to protect people from harm.

We identified closed cultures within the service, impacting on the handling of safeguarding allegations and incidents, with a lack of openness and transparency.

We observed staff receive limited support or have required measures in place to support them to maintain people’s safety and protect them from harm. Staff told us they felt unsafe themselves working with certain people living at the service, and this impacted on their confidence to proactively deal with situations as they arose.

The provider’s safeguarding policies, and training was not being consistently implemented into practice. We identified staff were reporting and alerting senior staff and the registered manager to safeguarding concerns, but this information was not then being reported onto relevant external professionals to safeguard people, and where applicable protect the staff team.

Feedback received from the provider identified a lack of regard for the importance of onward reporting to the local authority, but also professionals such as the police where applicable.

Risks for people were poorly managed, and where applicable did not involve people and their relative’s views and feedback. Many of the people living at the service required staff to pre-empt and respond to risk to protect them from harm, as they lacked the abilities and insight into risk to maintain their own personal and environmental safety.

People’s care records did not contain sufficient detail to ensure staff were aware of relevant risks and issues to maintain people’s safety, and where applicable the safety of visitors and members of the public.

People’s living environments were not maintained to good standards throughout, to reduce and mitigate risks. Condition specific assessments relating to risks associated with epilepsy were not in place, even though records showed healthcare professionals had discussed the importance of these being put in place by the service.

Where people’s relatives identified risks or approached the service for further details and clarification following incidents or accidents involving their loved ones, we identified their concerns were not proactively dealt with.

Staff and leaders demonstrated a lack of awareness into people’s risk presentation including historic risks where applicable. This was in part due to the quality of people’s care records, but also a lack of sharing of relevant information for example following an incident or accident.

Staff were expected to complete what people’s care records referred to as ‘dynamic risk assessments’ for example when supporting people to access the community. However, staff were not given training to ensure they understood what they needed to consider, and people’s care records did not evidence how decisions had been reached as this information was not being documented.

We observed staff to try to support people safely, but a lack of leadership and guidance was impacting on the standards of care and risk management they were able to provide. For example, staff told us they were, "Threatened with disciplinary action if people choked while being supported to eat." Even though they confirmed they were adhering to the speech and language therapy guidance in place, and ensuring food was provided in the correct consistencies, this threat of disciplinary action would not ensure they would feel confident to raise concerns with the management team if the person’s swallowing abilities were felt to change, or an incident happened.

Where people were assessed to require staff to use physical restraint and intervention to protect them from harming themselves or others, plans did not include or recognise the need to prevent use of prone, and the associated risks of asphyxiation. There were also questions around the practicalities of completing restraint in confined areas such as the person’s own flat, which had not been considered.

Where people were assessed as being at known risk of poor fluid intake, impacting on their health and comfort, or requiring welfare checks overnight for example when living with epilepsy, record were poor. This did not demonstrate required checks and completion of basic care was being completed.

People were living in a service in need for refurbishment. Many bathrooms were found to be visibly damp, and mouldy increasing risks to people’s health and wellbeing. The condition and cleanliness in some bathrooms would not have encouraged people to want to use them. The environment did not protect people from assessed risks of harm, for example large amounts of art and craft supplies were stored in an accessible room, and items were not accounted for to ensure these had not been inappropriately consumed or used as a means of causing harm to themselves.

Environmental risks were not thoroughly assessed to protect people from the risk of harm, for example a person had repeatedly experienced falls on the stairs, but the service continued to keep their room upstairs rather than looking at ground floor options to maintain their safety.

People’s clothing and personal effects were not being laundered to remove odours and stains. This raised concerns in relation to the management of infection, prevention and control, but also impacted on their presentation and comfort for example when out in the community.

Staff were not being protected from the risks of harm posed by the condition and cleanliness of the care environment. Staff did not have access to bodily fluid spillage kits to ensure they were able to maintain a clean and hygienic care environment. Staff were also at risk of coming into contact with bodily fluids without the required inoculations and risk management plans in place to protect them.

Consideration had not been given to blind spots and areas of poor visibility within the service and the grounds which impacted on staff safety. From reviewing the service’s accident and incident records we identified examples of where items such as rocks from the garden areas had been used as weapons against staff, resulting in injuries.

From reviewing accident and incident records, we identified staff were regularly being injured in the course of their work, including incidents increasing their risk of being in contact with blood borne diseases, and the registered manager and provider did not respond in line with nationally recognised guidance to maintain staff safety.

We observed areas of the service to be visibly unclean, we were particularly concerned for those people living with medical conditions affected by the condition and cleanliness of the care environment. Most people living at the service relied on the staff to maintain a safe and clean living environment.

We identified damaged and porous surfaces such as mattresses and floor-based activity equipment which had malodour due to the staff being unable to keep these items clean. Whilst we received assurances from the service that replacements would be sourced, such risks had not been identified from the service’s own audits and checks, therefore would not have been addressed without the inspection being completed.

Large items of furniture were not consistently found to be secured to the wall or floor to protect people from harm.

The provider’s own policies and procedures were not being followed to ensure people remained living in a safe, clean and hygienic care environment. For example, staff were found to be wearing jewellery, have painted finger nails, and not be bare below elbow when providing hands on care. The provider’s own environmental risk assessments were found to be poorly completed, and not be reflective of risks found during our inspection.

Sufficient risk management plans had not been implemented to support the service in the move from paper to electronic care records. For example, we identified there were no Personal Emergency Evacuation Plans (PEEPs) in place on the service’s electronic system, and the paper versions in the service’s grab bags were found to be out of date. Our findings were confirmed by the registered manager who advised the PEEPS needed to be updated following a visit from the local fire service who had given advice on additional information they felt needed to be reflected in people’s PEEPS.

People were not consistently supported by staff with the required knowledge, training and competencies to meet their assessed needs and risks. People’s individual preferences, for example in relation to the gender of staff supporting them with personal care tasks was not consistently respected, impacting on the individual but also placing those staff members involved at potential risk.

People required consistency in their staff teams and approaches taken to support them. People’s personal behavioural support plans reinforced the importance of this. Where people required 1 to 1 staffing support, we identified examples of where the allocated member of staff did not have specific training in place required to meet that person’s care needs.

Where people were known to pose a risk, or not respond well to certain staff members, sufficient preventative measures were not taken to mitigate these risks, and ensure the person was not placed in difficult situations to keep all involved safe.

Whilst staff consistently told us they liked working at the service and recognised the importance their role played to the lives of people living at the service, this feedback was not supported by our assessment findings. Most staff told us they felt they received the required training and support needed to meet their role and responsibilities; however, we identified risks in relation to the implementation of training and checks of staff competence in practice.

We identified examples of accidents and incidents where staff had been harmed in the course of their work. Staff on the whole told us they felt safe working at the service, whilst recognising the importance of their shifts being flexible, so they could move between people they supported if the shift became too intensive, physically or emotionally draining.

The registered manager told us they now formulated staffing rotas to try to ensure people received support from a consistent staffing team.

The provider had an ongoing recruitment plan in place, including recruiting staff from overseas. From our observations, we found these staff to be kind and caring, however, they did not always have a good understanding of English and had poor communication due to this. This impacted on how they communicated with people, and we were not assured that their induction and the training had assessed their competence and given them the knowledge and skills required. Our findings were reinforced by feedback received from people’s relatives. People’s relatives also confirmed language barriers impacting on their ability to speak with staff by telephone to source updates or information.

Overall, we identified there were not enough staff on shift at night time, to meet people’s assessed needs, but also in relation to use of physical intervention if this was required, and to safely manage an evacuation for example in the event of a fire, particularly in the event of needing to evacuate multiple units or the whole service.

Governance records showed, the provider and registered manager were not proactively protecting their staff team from being regularly injured by people living at the service. Where incidents had occurred, these were not being reported outside of the service, to ensure those staff received appropriate levels of support. This lack of openness and transparency did not demonstrate a culture of staff being valued and cared for by the provider.

Handling of internal investigations involving staff performance were of a poor standard and lacked detail to demonstrate how decisions and outcomes had been reached.

The service’s own governance record contained anomalies, therefore impacting on the registered manager and provider’s levels of oversight of staff completing training, supervision and performance appraisals.

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 were not receiving their medicines in a personalised way. We identified examples of where people’s medicine was not being given in line with the prescription guidance in place.

Where people experienced constipation, the care records in place did not provide guidance on when to escalate concerns to the GP or medical professionals. This was of particular concern, as some people’s epilepsy was affected by conditions such as constipation.

Where people did not consistently accept taking their medicines, the corresponding administration records did not accurately reflect this. Inaccuracies in the recording of what medicines the person had actually taken was vitally important to ensure external professionals had an accurate overview of medicines and their effectiveness.

Staff demonstrated varying degrees of knowledge and confidence in supporting people with their medicines but also in discussing individual support needs during the inspection visits.

Staff were responsible for maintaining an organised, tidy medicine room. The medicine room in The House was found to be visibly untidy, with poor arrangements in place for medication returns to the pharmacy and items of equipment required cleaning.

While some staff were able to tell us about a person’s medicine and fluid regime where they had these administered via a tube into their stomach, much of this information was not recorded in the corresponding care and medicine management records to ensure all staff working with this individual were fully aware of the processes they needed to follow.

The provider demonstrated a lack of understanding of local safeguarding thresholds for reporting medicine errors and incidents. We also found the investigation and recording of medicine errors to be of a poor standard.

Our findings were not reflective of the service’s own medicine administration audits which did not identify any areas of concern. We observed areas of risk within the medicines administration process which had not been fully assessed by the service. For example, staff needed to carry medicines between the first and ground floor in The Barns. Staff told us they put the medicine in a pot with another pot on top. From observing the care environment, we found this to be busy, with opportunities for the staff member completing medicines to be knocked, and or interrupted, increasing the risk of errors or misplacing medicines.