Versita Care Ltd

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 inspection we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to safeguarding, people’s safe care and treatment, staff recruitment and medicines management.

This service scored 38 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice. The provider did not have robust processes in place to investigate incidents and reduce the risk of reoccurrence. Relatives were not all fully satisfied they had been informed of all safety incidents or the circumstances surrounding any injuries to people. The registered manager completed incident forms, but did not record when staff de-briefs had been completed after the use of restraint. People each had an incident log; however, it did not provide a description of the incident to enable evaluation of the actions taken, without also reviewing the incident form. There was a lack of evidence to demonstrate whether the recommendations on the incident log to promote learning had been completed, by whom or when. The registered manager had regular contact with both the people and staff in each property and monitored the culture. People had access to professionals, family and friends outside of the service whom they could also raise any concerns about their safety with. Since the inspection the provider has told us that they have implemented improvements to their reviewing of incidents to aid learning. This is a recent development which has not had time to be embedded or for us to review its effectiveness.

The service 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. There were processes in place to promote effective transitions into and out of the service. However, these processes were not always consistently carried out and completed. For example, although risks had been identified during the assessment process, actions were not always implemented to mitigate them before starting people’s care. This meant that people’s experience of transitioning to the service was inconsistent, and their needs were not always fully met. Not everyone had positive views about the quality and effectiveness of people’s transition into the service. Some felt this had been poor, whilst others reported positive experiences. Not everyone was positive about how people were supported when distressed. Although risks had been identified during people’s initial assessments, the required actions to mitigate them had not always been taken prior to the start of people’s care. However, staff worked with health care professionals to understand what caused people's distress. Care plans were in place to support people to have a good day, and strategies were in place to prevent distress. Staff had access to these strategies to support people when distressed which they told us were followed.

The provider had limited understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). The need for DoLS applications had not always been identified. Safeguarding systems, processes and practices had not always protected people’s right to live in safety, free from avoidable harm. The service did not always share concerns quickly and appropriately. People were all supported 24 hours a day and were not free to leave. A DoLS application had not been requested for everyone lacking capacity to consent to this level of supervision and any restrictions in place. Although it was not the provider's role to make the application, they had not identified this and followed legal requirements. The provider had taken action to manage the risks of future harm to a person. However, there was a lack of evidence to demonstrate the person consented to the action taken, which impacted their privacy and dignity. The provider had taken the correct action to safeguard people when a complaint was received. However, there was a lack of evidence to show this was reported to the local authority for them to consider if any further action was required under safeguarding procedures. People’s incident logs noted if safeguarding concerns had been identified by the provider, but did not document if a safeguarding referral had been made. Staff had access to policies to guide and inform them in relation to safeguarding, equality and human rights, bullying and hate crimes. Staff had completed safeguarding training and understood what to report and how, they had access to relevant numbers.

The service did not work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe. Three people had been involved in a high number of incidents of either aggression or self-harm which required staff intervention and, or restraint. In order to manage their behaviours at such times, due to the level of risk either to themselves or others. Staff worked closely with external agencies to assess and mitigate risks to people; risk assessments were in place in relation to people’s mental health needs and behaviours. However, the provider and staff had not consistently taken measures to ensure the risk of people self-harming was as low as possible. Although people were continuously supported, the risks of them self-harming were not effectively mitigated and records showed processes to supervise their access to items with which they could self-harm were not always robustly enforced. People had access to lighters and on occasions sharp objects, which they had used to self-injure. People known to be at high risk of tying ligatures had ligature risk assessments in place, but these were dated the week after their care commenced. The provider had notified CQC of a safety incident and documented, that as a result a ligature emergency box had been put in place. This was a known risk and should have been in place before the person’s care commenced. People’s records showed they had been able to self-harm and to tie ligatures. A person's diabetes care plan instructed staff to check the person’s blood sugar level, but there was a lack of guidance about their normal blood sugar levels. This meant it was not clear when staff should seek additional support and advice if readings were outside the normal range.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care. Not everyone told us they felt confident every home environment was physically safe enough, to enable staff to manage people's risk of harm. The provider had not assured themselves the potential risks to people from their environment had all been minimised before they commenced people’s care. Although they had been made aware of the risks associated with the provision of people’s care, they had not always acted to mitigate these risks until after incidents. We observed although adaptations had been made and technology was being used to mitigate the risks in one environment, there remained risks. The provider had not ensured the housing provider had made suitable adaptations to the environment and reasonable adjustments to meet the individual needs of the people supported. A person was supported in a property, which was not physically large enough for the number of staff required to support them, to do so safely. The provider advised this had been brought to the relevant authority’s attention and was being addressed. However, people who required sensory items or sensory rooms to support their well-being had access to them. Staff identified property maintenance issues which were then escalated. We saw some actions were still in the process of being completed. Staff completed fire drills with people who had fire evacuation plans in place to enable staff to support them in the case of fire.

The service did not make sure staff were all sufficiently skilled and experienced to meet everyone’s needs and to keep them safe. Not everyone spoken with felt fully confident all staffs training and skills were sufficient, to enable them to fully understand some people's needs, support them effectively and to mitigate risks to them. However, some felt staff were well trained. Staff supporting some people lacked the required level of skill and experience. Staff had received training to support people with a specific mental health diagnosis. However, staff’s training in this area had consisted of a 1-day workshop which they completed a month after a person’s care had commenced. The provider still had not met the legal requirements for staff recruitment. Staff had gaps in some of their pre-employment checks and the provider had not assured themselves staff still had the legal right to work in the UK. Although the provider took action when we brought this to their attention, there remained gaps. However, everyone felt people were supported by enough staff and had consistency of staff supporting them. Staff received an induction to their role, supervision and an annual appraisal. Staff were also supported with their professional development and had the chance to undertake further social care qualifications.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading. People's home environments and equipment were visibly clean. We observed staff cleaning in different properties. Staff had completed infection control training and had access to relevant guidance. There were plentiful supplies of personal protective equipment. Staff in two properties asked us to wear face masks upon entering. These are not routinely required by national guidance unless a person being cared for currently has symptoms of an acute respiratory infection. The wearing of face masks can hinder communication where people with learning disabilities are dependent on seeing people's faces to aid their understanding. We brought this to the provider’s attention for their consideration.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People told us they received their medicines as required, however feedback from relatives was mixed. Not all relatives felt their loved one's medicines were the right level for them. People’s medicines administration information was not consistently and accurately recorded across all of their records. Therefore, it was not always recorded across their records when medicines had been administered and if this was appropriate. The provider could not demonstrate medicines people took as required to manage behaviours were always administered appropriately. Protocols to guide staff as to when to administer these medicines and medicine care plans were not sufficiently person-centred. People’s medicines care plans and risk assessments were not sufficiently robust to keep people safe. The provider produced people’s medicine administration records (MAR’s), and they lacked evidence of who had written them or checked them for accuracy. Some MARs had unclear guidance regards medicines doses or lacked information. People took medicines with them when they were away, however, there was a lack of records to support this safely. People’s records did not demonstrate the physical health monitoring which had taken place as required for certain medications they took, or records did not include key health information for specific medicines. However, for those at risk of not complying with their medicines, plans were in place. People’s allergies were consistently and clearly recorded.