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• 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

Medicine management required improvement, accident and incident oversight was not always effective as not all accidents or incidents had been reported appropriately to the relevant safeguarding authority or CQC. There was also limited information found when investigating or analysing accident information. Deprivation of liberty application and authorisation oversight was not always effective. The registered manager did report these concerns retrospectively following the assessment. There were enough staff to support people and recruitment processes had improved.

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.

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 told us they felt safe at the service. A person told us, “I feel safe here, the staff make me feel safe.” A relative told us, “The moment, [family member] came here my anxiety went. They are surrounded by staff reassuring them.” While the people we spoke with expressed that they were generally happy with their care, our assessment found the oversight of safeguarding processes required improvement.

Staff had completed safeguarding training and staff were aware of who to report to both internally and externally. A staff member told us, “I am here to protect people, if something were not right, I would report it. Above [registered manager] there is social services or CQC.” Whilst staff were aware of reporting processes, we identified some incidents that had not been reported appropriately. This meant further learning in this area was required.

Throughout the assessment we observed staff supporting people safely. This included responding to people’s requests for support. People were observed being relaxed in the presence of staff.

Safeguarding policies and procedures were in place and staff had received training in this area. However, not all accidents and incidents we reviewed had been reported to the relevant safeguarding team or to CQC. Following the assessment the registered manager reported these retrospectively. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found there was not an effective process in place to manage DoLS applications or authorisations. We identified two people at the service where applications had not been sent for authorisation, we also identified that some applications had been sent after the authorisation had expired. The management team were not aware of what conditions had been put in place so these had not all been followed up or met. Following the assessment the service sent the appropriate applications and followed up all conditions present as part of people’s authorisations.

People were involved in their plan of care including risk plans. A relative told us about recent concerns with their family members care and how risks had increased. They told us at all times the service involved them. However, as recorded in this quality statement some environmental risks had not been fully explored which potentially could have impacted on people.

Staff knew people well and had a good understanding of what people’s risks were and what was in place to reduce those risks. We did identify some risks during this assessment the service the registered manager had not fully mitigated. However, these were followed up immediately following the assessment by the registered manager and deputy manager.

Throughout the assessment we observed staff providing safe care to people whilst respecting their rights and choices.

At the previous inspection we recommended the provider referred to current guidance to ensure risk assessments are regularly reviewed to ensure they remain up to date. At this assessment we found risk assessments had been reviewed regularly. However, oversight of risk in other areas required improvement. We identified wardrobes not secured to the walls and risks to people from an open staircase had not been assessed or explored. Following the assessment the registered manager had taken appropriate action. Oversight of accidents and incidents was not robust. When we reviewed accidents and incidents at the service the accident information recorded by staff had not always been followed up or investigated in full by senior staff. There was very little information used from accidents and incidents data to identify any potential trends or themes. When we visited the service on day 2 the registered manager had introduced a different process to analyse information from accidents and incidents more effectively. A professional told us, “A person came in following a crisis, we had lots of meetings and staff members were able to give us a really good understanding of the person.”

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 and relatives told us there were enough suitably qualified staff to support people. A person told us, “There is enough staff to look after me, I have a buzzer to press, and the staff come in to see me, they help me get washed and dressed.” A relative told us, “I do think they have enough staff; it has never felt like they were short of staff. There is a team of experienced seniors.”

Staff told us the staffing levels provided met people’s needs. A staff member told us, “Yes, we have enough staff, there is no difference at the weekend and we staff to the same levels. We do activities as well.” Staff were also positive about the training they received at the service and told us they were supported to obtain additional nationally recognised qualifications.

Throughout the assessment we observed staff responding proactively to people’s requests for support. The interaction between staff and people was positive and evidenced staff knew people well.

The registered manager told us they had a consistent staff team and recruitment was on going with staff waiting to start pending recruitment checks. At the last inspection we recommended the provider ensured recruitment checks are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which provides reference to the recruitment checks and documents required when appointing staff. At this assessment the staff files we looked at did meet the requirements of schedule 3. Staff had undertaken training to meet the needs of people using the service. This included specialist training, for example in learning disability and autism and dementia. Training was refreshed at regular intervals so that staff stayed up to date with current practice.

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 and relatives were happy with the way their medicines were administered and managed. A person told us, “The staff are very professional about medicines and treatments, I always get mine on time. “ However, whilst people were happy, we found the oversight of medicines management required improvement.

Staff told us they had received training to administer medicines and their competency had been checked. A staff member told us, “The registered manager and Deputy manager complete medicine audits. If there was an error, I would record everything, then ring 111/999 to seek advice alert the registered manager and the local authority.” The Deputy told us, “We do medicine competencies with staff. The community pharmacist is very good if we need support.”

At the previous inspection we made a recommendation the provider reviews people's current prescribed when required PRN medicines and take action to update their practice accordingly. At this assessment whilst we saw some improvements in this area more work was required. Other areas of medicine oversight also required improvement. One person was receiving their PRN medicines consistently and there was limited evidence recorded to identify why this was or if the medicine once administrated had been effective. We also identified some reconciliation issues where the count recorded did not match the contents and handwritten medicine administration records (MAR) did not always contain 2 signatures. Some medicines required additional security and storage and whilst these medicines reconciled correctly there was no evidence of regular checks being carried out for these medicines.