74 Old Ford End

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 good. At this inspection 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 regulations related to safeguarding and safe care. A person had not been safeguarded from unnecessary sedation. Accident and incident forms were not always completed. Care plans did not always contain enough information on managing risks. Protocols for ‘as required’ medicines were not always in place. Environmental safety and infection prevention and control risks had not always been managed.

This service scored 44 (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 culture of safety. Accident and incident reports had not always been completed. For example, following an incident where a person choked, this had not been documented as an incident or investigated appropriately. This placed this person at increased risk of harm. This increased the risk of lessons not always being learnt to continually identify and embed good practice.

The service did not always maintain safe systems of care to manage risks people could experience. We found shortfalls in the provider's systems always being established or effective to ensure people's health and safety were always assessed and monitored. This is covered more in the safeguarding and involving people to manage risks part of the report. However, records showed people were supported to attend appointments with external health professionals such as GPs, mental health services, and dentists.

People were not always protected from abuse and improper treatment. People were at risk of over-sedation as the provider had failed to identify they had received medicines with sedative effects without there being a documented or justified cause to do so. Although staff had received safeguarding training, they, too, had not identified this concern. As a result, we shared our concerns with the local authority’s safeguarding team. Failing to recognise potential safeguarding concerns and escalating these appropriately placed people at increased risk of harm.

The service did not always plan care to meet people’s needs safely. People were at increased risk of avoidable harm as the provider had failed to fully assess known risks, such as swallowing difficulties and risks relating to emotional distress. However, there were also examples of good practice, such as a person’s care plan identifying they did not like loud and busy places. Staff could tell us how they supported people with individual risks, such as falls and epilepsy.

The service did not always detect and control potential risks in the care environment. During our first visit, we identified concerns with a trip hazard in a person’s room, the storage of cleaning products, window restrictors and an unsecured crawl space containing pipe work. The provider took prompt action in response to these concerns during our assessment. Requirements in relation to fire, electrical safety, water and lifting equipment were managed safely. People had been supported with assistive technology such as a personal alarm and epilepsy sensors to promote their safety.

The service did not always ensure there were enough staff deployed, and there were no established systems to ensure people received the correct amount of one-to-one care. This increased safety and wellbeing risks to people. In response to our concerns, the provider took action to review their future staff scheduling and told us they would implement a system to monitor and ensure people received one-to-one care. Staff were recruited safely and received effective support, supervision and development.

The service did not always assess or manage the risk of infection. We identified concerns in relation to food storage, fridge and freezer temperatures and the condition of handrails and furniture which did not promote good infection prevention and control practices. In response to our concerns the provider fitted new handrails and made improvements to promote safe food storage.

The service did not always make sure that medicines administration was safe. In addition to our medicines concerns highlighted in the safeguarding section of this report, we found improvements were needed to people’s protocols for receiving ‘as required’ (PRN) medicines to ensure they were in place for all prescribed medicines and contained relevant safety information. This increased the risk of people not receiving medicines safely and when they needed them. However, medicines were stored safely, people received their medicines in the way they preferred. Where errors had been identified, these were investigated, and staff competency was reassessed.