Sister Winifred Laver Promoting Independence Centre

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. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed safely and managing risk.

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 provider did not have a proactive and positive culture of safety based on openness. They did not listen to concerns about safety and did not analyse or report safety events consistently. Lessons were not learnt to continually identify and embed good practice. Individual incidents were reported to the provider’s in-house health and safety team. However, there was no evidence available to us to demonstrate the provider analysed incidents effectively to identify trends and learning. This meant opportunities were limited to take proactive action to keep people safe. Some incidents had not been reported to the relevant bodies, such as the Care Quality Commission and the local authority safeguarding team. Some of these incidents had resulted in injuries to people. Support and therapy staff told us they could make suggestions to management but felt they didn’t listen to their views, and they did not receive feedback.

The provider 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. They did not always make sure there was continuity of care, including when people moved between different services. The provider did not always receive enough information in referrals to understand people’s needs and determine they were suitable for the service. Support and therapy staff told us this placed them under pressure as people’s needs were too complex for the service and the number of staff deployed. The provider’s ‘standard operating procedure’ for the service stated the service was only available for people who had aims of reablement within a 6 week period or 4 weeks maximum for a short term placement without reablement goals. However, there were some people who were living at the service who did not meet this criteria. The provider had also determined they no longer had any care and support needs and had discontinued their care plans.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not share concerns quickly and appropriately. Although most people gave positive feedback about safety, this was impacted through a lack of robust action to address safeguarding concerns. There were incidents which occurred within the service which were either not reported to local authority safeguarding teams in a timely way or not reported at all. Some of these incidents had resulted in people being injured. Support and therapy staff told us about regular medicines errors occurring which were not reported appropriately. Staff also told us they would speak up if they had concerns about people’s safety.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People’s care plans lacked sufficient information about people’s individual needs and preferences, including the support they should receive from staff to keep them safe. Risk assessments had not been completed to keep people safe from harm. This included risks associated with falling and choking. The provider brought in additional support and was updating care records to reflect people’s needs. Following incidents there was no evidence risks had been reviewed and adaptations made to people’s care implemented to maintain their safety. We observed one person received care which was not consistent with their care plan around eating and drinking. Staff were not always visible in communal areas to respond to potential risks and people’s requests for assistance. Support and therapy staff told us mistakes were often made because staff were over-stretched.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service was newly built especially to provide care and support to people. Environmental risk assessments had been completed. The first review was not yet due as the building had been open less than a year. Health and safety checks were up to date to help maintain a safe environment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. We observed staff were not always visible in communal areas to supervise and respond to people’s needs. Support and therapy staff consistently told us there were insufficient staff to meet people’s needs safely. They commented they did not have the ability to give people the quality time they needed, due to the complexity of people’s needs. The registered manager was unable to provide us with evidence about how staffing levels and skill mix were determined to ensure they were appropriate to meet the needs of people living at the service. New staff were recruited safely.

The provider did not always assess and manage potential risks of infection. The service was clean and domestic staff were visible throughout the home completing cleaning duties. Staff had completed infection prevention and control (IPC) training and had access to personal protective equipment (PPE). During a lunchtime observation staff washed dishes in the kitchen sink whilst also serving people food, rather than using the dishwasher. Support and therapy staff also told us about this practice as being usual and said it was a potential infection control risk. This was due to the number of people living at the home. They also said this potential risk had been raised with management but they were not listened to. The provider had not assessed this potential risk to minimise the impact on people.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The provider’s medicines policy was not specific to the service or the way the service managed medicines. Current temperature monitoring was in place, however 2 of the 3 fridges did not have working maximum and minimum thermometers. Although staff told us this had been reported, no actions had been taken to address this. Stock checks of controlled drugs (medicines liable to misuse) were not completed frequently. Medicines Administration Records (MARs) were not always completed in full. Where people had multiple MARs, each front sheet did not have the person’s photos or risks documented. MAR charts were handwritten and countersigned as accurate. However, the details were not correct, and others were not countersigned. Medicines care plans were not always in place. For the people who did have a medicines care plan these lacked detail and were not person centred. Staff medicines competency assessments were provided after the inspection. However, some were not completed in full. Quality assurance systems had failed to identify and address this. There was not a robust process on admission to ensure all medicines people were prescribed were documented. For several people no hospital discharge summary could be found to confirm what medicines they had been prescribed. External resources had been sought to assist with improvements and an action plan had been developed. However, this lacked detailed information about specific actions needed and realistic deadlines. Some people were supported to self-medicate and assessments had been completed to ensure the right level of support could be provided, as the person progressed through their stay.