Susan Hampshire House

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 assessment we rated this key question requires improvement (January 2023). At this assessment the rating remains requires improvement. This meant some aspects of the service were not always safe and there was insufficient assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to staffing and safe care and treatment. We found staffing levels were not always sufficient to ensure people were safe, and there were significant gaps in staff training and supervision. Actions were taken to make improvements during our inspection, but this was a breach of regulation. The service did not always work well with people to understand and manage risks. We found risk assessments and service procedures had not always been followed and records and reports were not completed accurately or consistently. This meant staff were not always able to take appropriate actions to mitigate risks. We saw improvements had been made to the premises and infection control, although further action was still required. Checks were completed on fire systems and equipment and work had been carried out to ensure people would be safe in the event of a fire or emergency.

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.

The service did not always have a proactive culture of safety. They did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The new acting manager was working with staff to promote a learning culture. Team meetings and supervision had recently been re-established. A team day had been held jointly with staff and people who lived at the service. We saw the visual ‘Pathway to the Future’ they had developed. This showed how the team would prioritise safety and learning and develop the culture with positive changes.

The service worked with people and other agencies to establish and maintain safe systems of care in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services. People told us they were supported to attend healthcare appointments, and other professionals were involved in their care as necessary. Specialists such as the local Community Learning Disability Team, neurology and speech and language professionals supported people who lived at Susan Hampshire House. Staff were supporting people to find dentists in the local area so everyone could receive oral healthcare. When people experienced distress, staff used available information and their knowledge of individuals to provide support and meet their needs.

People were not always kept safe from avoidable harm because they were not always protected to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm or neglect.

Staff told us what they would do if they were concerned about a person living at Susan Hampshire House. However, staff had not always shared concerns quickly and appropriately. After a person fell, staff did not take necessary actions. This meant the person stayed on the floor for an extended period and did not receive timely medical attention. This incident was being investigated by the manager and the local safeguarding team. Records about actions taken after incidents or accidents were not always clear, and managers were not promptly contacted. From the records we saw, only half of the staff team had completed safeguarding training. People’s mental capacity had been assessed and decisions which had been made in the individual’s best interests were documented. When people were subject to restrictions to keep them safe, these were monitored to ensure they remained necessary and proportionate.

The service did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People’s safety was not always assessed, monitored or managed effectively. For example, one person was at risk of malnutrition and had lost weight. However, checks of their weight and skin integrity had not been carried out monthly, in line with good practice, and a nutritional screen had not been regularly completed. Some food and fluid charts had gaps, so it was difficult to ascertain whether one person was receiving enough food and fluids to keep them safe and well. These omissions put people at risk. During our visit, we saw a person who was at risk of choking eating their lunch without staff support. This person had recently experienced a choking incident. Another person had epileptic seizures, but staff did not record these consistently or accurately. In these ways, people did not always receive safe and supportive care which met their needs. People’s support plans included ways to avoid or minimise the need to place restrictions on people. Risk assessments were in place to keep people safe. These were clear, but staff did not always follow risk assessments or work with people to understand risks and manage safety.

The service detected and controlled potential risks in the care environment. They usually made sure equipment, facilities and technology supported the delivery of safe care. We raised some shortfalls with managers. The home was clean and free from odour. There was a programme of ongoing maintenance, refurbishment and decoration. Furniture had been replaced since the last inspection and the small lounge on the ground floor had been refurbished. This area was more homely. We were told this was going to be changed to a sensory area. Plans were in place to refurbish the kitchen during December. People who lived at the service were consulted about changes as far as possible. At the last inspection, the manager told us about changes which were required to improve fire safety. A fire risk assessment had been carried out and changes had been made. Emergency plans were in place to ensure people could be kept safe. The living environment and equipment in it were checked to make sure they were safe. Adaptations such as key codes on doors, restrictors on windows and covers on radiators all helped to keep people safe. Staff told us the emergency lifting cushion was broken. This had stopped them being able to help a person in the safest way. We were also told some equipment for monitoring people’s health was not reliable. We shared these issues with the manager and senior management team.

There were not always enough qualified, skilled and experienced staff. The provider did not always make sure staff received effective support, supervision and development. A member of staff told us they felt rushed, had little time to spend quality time with people and often left their shift not feeling they had completed all they needed to do. One member of staff told us they came in on their day off to support people to go out in the community. The number of staff on each shift did not meet people’s needs. Some people needed full support from 2 members of staff, and several needed support with eating and drinking. A member of staff told us when people were being supported with personal care, others were often left with no supervision. We saw evidence of this during our visit. The manager told us they had recruited new staff. This included care staff, an activity coordinator, an additional housekeeper and a cook. Recruitment processes were robust and relevant checks were carried out before new staff started working at the service. Some staff told us they did not receive a comprehensive induction when they started in post. This was confirmed by records we saw. One member of staff could not recall when they last received supervision, and they last had an appraisal 2 years ago. Another member of staff said they had worked in the home for 6 months but had not received any supervision or training. The records we saw showed significant gaps in staff training. We shared this information with the manager and senior management team. Management changes had impacted on supervision, appraisals, training and staff induction. This meant people were not always supported by staff with the necessary skills or competencies. After our assessment, we received assurances that senior managers were supporting supervision, priority training had been identified and staffing levels reviewed and increased.

The service assessed and managed the risk of infection. They detected and controlled risks and shared concerns with appropriate agencies. We found the service to be clean and free from odours. People and their relatives felt the home was clean and tidy and no concerns were raised. An infection prevention and control policy was in place which reflected relevant national guidance. We were assured the provider was protecting people, relatives, staff and visitors from the risk of infection.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Staff had not followed one person’s epilepsy protocol, and this put the individual at risk. Staff told us, and we saw from records, that not enough staff were trained to administer emergency medication in the event of a seizure. This was particularly challenging during night shifts. After our visit, the acting manager told us staff rotas had been reviewed to ensure there was always a member of staff on each shift who had completed this training. More staff needed to be trained to administer all medicines. Further training had been scheduled in December 2024. The assistant manager had recently started in post and was responsible for reviewing and managing medicines within the home. They found shortfalls in records which they had addressed. For example, medicine fridge temperatures had not been checked, but this was now being done. Some people did not have individual protocols for homely remedies. These are medicines that can be purchased without a prescription and used to treat minor illnesses. The GP had been consulted and protocols were written after our visit. The assistant manager had also introduced daily and weekly stock checks of medicines. These actions contributed to ensuring medicines and their management were safe and met people’s needs and preferences.