Ordinary Life Project Association - 5 St Margaret's Gardens

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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 3 quality statements in the safe key question and found breaches of the legal regulations in relation to supporting people safely, safe staffing and safeguarding. Staff were not always appropriately trained and assessed. This meant the provider could not be assured people were supported by qualified and competent staff. A safeguarding issue had not been referred to the local council in a timely way which put people at further risk. People’s records were not always accurate or up to date.

This service scored 62 (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.

One person could at times put themselves at risk. They told us the registered manger had worked with them using a risk assessment to identify why they did this and how they could reduce these risks. We saw the person had reviewed and signed the risk assessment in place.

Not all staff had completed the provider's mandatory safeguarding training but the registered manager allowed them to lone working in the house. The registered manager understood what to do when they had a safeguarding issue but had not reported a recent safeguarding issue to the local council in a timely manner. Some staff we spoke to understood what safeguarding meant and what to do if they had concerns about a person, others were not able to explain all actions they should take if they were concerned about someone's safety.

The service was not always being managed safely. There had recently been an incident in which people and a member of staff were involved and the member of staff had been injured, however the provider failed to report this to the local authority safeguarding team in a timely way. One person was using the whole of their mobility element of their Personal Independence Payment on a vehicle for the house, the registered manager could not demonstrate this expenditure had been reviewed by them or any external supports such as an advocate nor had they assessed if this expenditure was in the person’s best interests. The safeguarding policy was not detailed enough to enable staff to understand how to safeguard people. The policy was not in line with current local or national guidelines, this meant people were at risk of not being safeguarded properly.

Most people told us they were not always able to do the things that were important to them. However one person told us they were supported to do the things that were important to them.

The registered manager recognised paperwork was not up to date and people were not always receiving the appropriate support to enable them to do the things they wanted to do. Staff we spoke to said people had not been able to do things they wanted to do but they had now had a meeting and had been asked by the registered manager for ideas of what activities people would like to do in the coming months.

We saw from records 1 person was involved in reviewing some of the risks that were associated with them, however not all recognised risks were being assessed. There were no clear guidelines in the agency file for agency staff on how best to support them. This meant the provider could not be assured agency staff would know where to find the information in a timely way.

Three people’s risks were not being reviewed and updated in line with their changing needs. this put people at risk of receiving support that was not appropriate. One person who had specific support needs had a Personal Evacuation Plan (PEEP) that did not provide clear guidance in how to support them to evacuate safely in case of fire. When this was addressed by an inspector with the registered manager they said another service user could help them evacuate. This put both people at risk of potential harm. Another person had 2 different PEEPs one stated they should leave the house first and the other they should leave last. This could cause confusion and could put the person at high risk in the event of a fire.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

One person had daily commissioned hours of 1 to 1 support but was not receiving their full amount because the hours were being used to support other people in the house. This meant the person was not able to chose to do activities of their choice.

Staff told us there were not enough staff working to be able to ensure all people got the correct support. After a significant incident there had been an increase in staff working in the house. However staff told us that they did not feel they were adequately supported by the provider when working with 1 person who had specific support needs. Some staff told us they had not attended all mandatory training courses before lone working in the house. This put people at risk of not receiving support from appropriately trained staff. The provider showed us training records which demonstrated that 1 member of staff had only attended 2 courses in the first 6 months of their employment, when asked the registered manager acknowledge that this was the case but they had put this member of staff on the rota to lone work regularly. This put people at risk of poor support.

We saw that staff were not working in a person centred way with 1 person. The inspector was instructed by a member of staff how best to engage with the person but there was no evidence this was the correct way to work with them as there was no record of this instruction in their care plan. The inspector observed this person being isolated from the other people in the house and could find no evidence in care plans this was an appropriate and reasonable way to work with them. Inspectors saw that some staff who knew people well were able to support people safely.

One member of staff had been employed for 6 months but had only completed 2 training modules. They had not completed medicine management training but were lone working in the service where there was a service user who required as required (PRN) medicine. Neither had they attended Positive Behaviour Support training which would have enabled them to develop the required skills to support people in a safer way. The provider had 2 new staff members working together on the second day of the assessment. This was due to an incident that had recently occurred. Neither of these staff had attended the provider's mandatory training courses including safeguarding training and PBS training. This left the services users and staff at risk of avoidable harm.

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.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.