Head Office

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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

We assessed all quality statements within safe, and found areas of concern. The rating for safe remains inadequate.

We have identified 4 continued breaches in regulation in relation to safeguarding, safe care and treatment, staff training and staff recruitment .

We found people were still not always protected from the risk of harm as their risks were not always managed safely and not all incidents had been reported to the local safeguarding team

Sufficient staff were still not being deployed, staff had not received adequate training and staff recruitment checks were not always sufficient to evidence safe recruitment procedures had been followed.

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.

People’s experience was not always positive due to learning not being implemented.

People continued to be put at risk as lessons had not been learnt from incidents or accidents and therefore had not been shared with staff. For example, at the last inspection we identified risks associated with people being given inappropriate foods, at this assessment we continued to find concerns with people being offered food that were known to be a risk to them.

Staff told us they learnt from incidents and lessons learnt were shared within staff teams. However, at the previous inspection we identified concerns with incidences of distress not being evaluated. During this assessment, the registered manager told us they still did not review or have a complete oversight of incidences of distress. This meant they did not assess or identify any trends or patterns and therefore, could not be assured mitigating strategies were effective and staff understood the mitigation.

Feedback we received from partner agencies raised concerns with how the provider learnt from previous incidents and that people’s experience was not always positive due to learning not being implemented. Information we received from partner agencies highlighted issues with the provider not learning from previous lessons or putting mitigating strategies in place to reduce the risk of re occurrence.

We continued to find issues with the recording and reporting of accidents and incidents. For example, one person had multiple bruises identified on their body. However, there was no incident record relating to these. This meant people were put at increased risk of harm. We continued to raise concerns at this assessment regarding lessons learnt and identifying and mitigating, and trends or patterns. The accident and incident matrix had a section within the spreadsheet to record lessons learnt. However, this section had been left blank for most records. We reviewed the ‘trend analysis’ paperwork during the assessment and found trends or patterns linked to staff members had not been reviewed or assessed.

The registered manager told us, “Staff use communication sheets where people use different services. This helps relay information that is important, such as what people have had to eat. We ensure that transitions into settings are centred around the individual.” They went on to tell us, “We plan the transition. This can take as long as needed – a week, a month, several months.” We however found this approach was not consistently followed and embedded.

Feedback we received from a partner agency evidenced when people required medical advice for known risks this had not always happened. This raised concerns with the partner agency that risk information would not be handed over putting people at risk of harm.

The registered manager told us they carried out assessments for people potentially moving in to one of the supported living services. They said this took place in an environment that was comfortable for the person, such as at home, or at college. We found the process was not fully effective as we had been told a new provider had not been given accurate information about a person’s needs. This meant the provider could have accepted the care package and then found they could not meet the person’s needs.

Although relatives did not state they had any concerns, we found people were not always protected from the risk of abuse and neglect.

Not all staff had received safeguarding training. Although staff told us they understood how to recognise and report the signs and symptoms of abuse. Records evidenced this was not always put into practice as not all unexplained injuries had been reported. The registered managers did not fully understand the principles of the Mental Capacity Act (MCA). For example, inspectors found a relative had made a decision regarding how a person was allowed to have their hair cut. On discussion, the registered manager had not discussed this with the person or established if this was in the person’s best interest. Inspectors explained the principles of the MCA and what the registered manager should do to ensure the act was complied with.

As we observed unsafe manual handling practices (reported under: Involving people to manage risks) and the concerns found with mental capacity assessments (reported under consent to care and treatment), we could not be assured people were safeguarded. We also found the provider did not recognise these issues as safeguarding concerns and had failed to report these or investigate them to prevent reoccurrence.

People continued to be put at increased risks from restrictive practice. Records of interventions used were not always clear to establish if physical intervention has been used and what type of intervention. For example, one person records state ‘high level intervention was required.’ However, there was no record of type of intervention used. Incidents were still not always being raised as safeguarding. For example, one person’s care notes recorded a physical incident between two people, another person’s records evidenced an unexplained bruise, neither of these had not been raised as a safeguarding concern. Systems and processes were not effective in ensuring people were safeguarded against potential abuse and harm.

People told us that staff did not always discuss their individual risks or what mitigation strategies were implemented to reduce these known risks. One person said, "They [staff] have never told me about the risks associated with (health condition) I asked what the diagnosis meant, and they told me but nothing about the risks." Although relatives did not raise concerns, we found the risks associated with people’s care was not always managed in a safe way. We did not see evidence that people were involved in the management of risks.

Staff told us at one of the settings that the home currently did not have any thermometers to check water temperatures and that staff had been requesting one for many months. One of the people living there was at risk of scalding from hot water. Therefore, staff were not assured risks were mitigated. Staff told us they understood people's risks. However, due to the concerns with recording and mitigation of risk new staff and agency staff would not have the information to keep people safe.

We observed poor moving and handling practices. Inspectors observed staff using equipment inappropriately and they also observed staff not always using the identified equipment to support a person to safely move. For example, one person was seen being moved without their footplates being attached to the wheelchair, This put people at risk of entrapping their legs/feet and put people at increased risks of falls and injury.

People were still not fully supported to ensure risks were assessed and mitigated. People continued to be put at increased risks due to records not being clear, staff not following mitigating strategies and equipment not being in place. Risk assessments were still not always in place or detailed enough for risks associated with diabetes, choking, distress, scalding, pressure damage and known health conditions. We could not be assured these risks had been mitigated. People’s health conditions were not always fully recorded with the signs and symptoms staff should be aware of to ensure appropriate medical support could be sought in a timely manner. Strategies that had been implemented were not always completed or recorded. Systems and processes to review information was not effective. Audits completed prior to the assessment had not identified the missing or conflicting information. This put people at increased risk of harm.

People did not always have a good experience in relation to their environment. For example, in one supported living service, there were no thermometers to check water temperatures and as such this meant people may not be able to wash in a safe way.

The registered manager told us, “[Second registered manager] visits the homes once a week to check safety aspects. We carry out different audits which include the environment, health and safety and infection control. We ensure maintenance checks are carried out like for profiling beds or wheelchairs.”

Environments in the supported living services were basic and not always homely. Furniture was functional and the décor was stark. However, the environments were such that people had sufficient space to move around and we saw that most people had their own individual chairs they liked to sit in as well as some personalisation in their bedrooms. Gardens were level and the settings we visited had direct access into the garden or a ramp to aid access. However, we found no evidence people's choices were considered in relation to the communal environment.

Although the provider had a system in place to report environmental issues, the response to requests did not always happen in a timely way. For example, in the case of one supported living setting waiting for several months for thermometers, despite having requested them.

We received mixed views on staffing levels from people using the service. However, records still indicated there were not always sufficient, adequately trained staff deployed on each shift to meet each person’s holistic needs. One person told us, “There are enough staff most of the time, but if staff are off, it can affect us. We are not able to go to [specific place named].” One relative said, “There are not enough staff all of the time.” Another relative said, “I have had to raise before that there are not enough staff in [specific house].” Some relatives raised concerns with staff understanding and training. A relative said, “[Due to the person’s specific needs] from my point of view they (staff) are not qualified enough to deal with it.”

Staff told us staffing levels were sufficient and they were happy with the level of training and support they received. One staff member said, "There are enough staff or service users. Some staff comes from agency also. Sometimes if someone gets sick then we inform to manager and she arrange staff from agency." Another staff member said, "We received our training on Citation, face to face and practical. For me, yes from these trainings it has helped me to progress as carer." However, records evidenced staff had not always received the training required to provide safe care and to understand the specific risks to people. For example, one person required support with hoisting. However, not all staff who worked in the house had received this. Another person required support with a medicine that required specialist training. We found that staff who had signed to evidence they had administered this medicine were not all trained to do so.

Although we observed appropriate staffing levels during our site visits, records evidenced staff were working excessive hours and did not always have an appropriate break between shifts. For example, one staff member worked for 8 nights in a row totalling 88 hours. This put people at increased risks. We also observed when staff were still in their induction and were completing 'shadow shifts' they were at times used as the 2nd staff member when a person required two staff to support them to complete a task or activity. (A shadow shift is a shift that's dedicated to the observation of another worker with the purpose of gaining a better understanding of their role and the tasks it involves.) People were put at increased risks as staffing levels were not always appropriate for the needs of the people being supported. At one of the settings the provider had identified that five staff were required throughout the day to meet the needs of the people living there. However, we found on 48 days between 2 March 2024 and 28 April 2024 there were not five staff on duty. Some shifts had three staff and others had four staff members deployed. This put people at risk of not having their needs met due to a lack of staffing. The registered manager told us, staff should not work more than four long days or five nights in a row (without a day off). However, when we raised concerns that staff were often working in excess of this, the registered manager stated they would investigate and start completing spot checks to ensure staff don’t work excessive hours.

Recruitment records did not evidence the provider was ensuring safe recruitment procedures were followed. We found concerns with staff recruitment records and references supplied for staff. One staff member had a reference from a company that was not recorded on their application form, another staff member did not have a reference from their last care employer. Systems and processes had failed to identify and mitigate the concerns found with staff working hours, staffing levels, staff training and safer recruitment. This put people at increased risks of harm.

People or relatives did not have any concerns in relation to infection control practices within their supported living setting. A relative had fed back that their family members home was always very tidy and their room immaculate.

The registered manager told us, “We have infection control procedures in place and staff have to sign to say they’ve read them. We do audits and it is clear on the audits whose action it is if there is a gap. We ensure we have personal protective equipment and we have recently introduced a mattress check, as there was an issue with this in one of our care homes.”

In the settings we visited, we did not have any concerns about infection prevention and control. The environments were neat, clean and hygienic. When we observed one person have an accident, staff immediately fetched a mop and water to clean it up, ensuring that other people stayed away to keep them free from risk of harm. Staff were seen wearing suitable Personal Protective Equipment (PPE) when attending to people’s personal needs.

Household tasks were shared amongst staff. This helped ensure that settings remained clean and the workload was being shared amongst the team.

People were put at risk from medicine management. Staff had not always being trained sufficiently to administer certain medicines and we found concerns with a person being given the wrong dosage of medicine on multiple occasions. One person had been prescribed a stomach medication which was to be given to them if they had not opened their bowels in a 72-hour period. According to this person’s notes they had not had a bowel movement for 4 days and yet staff had not given them their prescribed medicine. A relative told us there had been 3 medicines errors with their family member. Staff had not identified these and it was the relative who had picked these up. They told us they felt there was a lack of robust competency checking of staff.

Staff told us that due to insufficient staff they did not always follow respectful best practice in relation to medicines administration. One staff member told us, “I know I shouldn’t (give people their medicines at the breakfast table) but with only 4 staff there isn’t time to do it when I first get here (on shift) as people need personal care support.”

Medicines practices did not always demonstrate a respectful approach. We saw one staff member put one person’s eye drops in whilst they were having their breakfast with other people. We also saw a staff member give other people their medicines at the breakfast table.

Systems and processes failed to identify when a person had been given too much medicine. The medicine administration audit completed had not identified two occasions where staff had administered double the required dose to a person.

Systems and processes were ineffective in mitigating any concerns found within people’s medicine administration records. For example, we found two audits (for January 2024 and March 2024) had identified the same three issues. However, there were no actions taken to rectify these concerns or to identify they had been found on previous audits.

Systems and processes had failed to identify when staff were not adequately trained to safely administer medicines. These concerns put people at risk of not receiving their medicines as prescribed.