New Boundaries Group - 329 Fakenham Road

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

Systems were not in place to assess, monitor, and mitigate risk in relation to incidents that occurred in the service. No evaluation or learning to improve practice from incidents had taken place. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes were not operated effectively to prevent and investigate allegations of abuse. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Requirements under the MCA and DoLS had not been met. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Actions to mitigate risks of harm to people were not effective. This included in relation to the physical environment. Not all risks to people had been assessed and considered. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Recruitment procedures had not been operated effectively to ensure staff employed were fit and proper. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were supported by enough staff who understood their needs and how to meet these. People and their relatives told us they felt people were safe living in the service. Staff received training and supervision to carry out their role. They understood the importance of supporting people’s decision making. Staff and people felt able to discuss any concerns they might have. There were positive relationships between people and staff.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us when incidents occurred in the service these were not routinely discussed with them. A staff member told us, “There is nobody that actually comes, like a manger, that sits down and looks at it [the incident] to see where we go from there". Staff told us they felt able to raise concerns with the management team. The management team told us they were unable to provide information on incidents that had occurred in the service.

There was no system in place to review incidents and identify trends. No analysis of incidents was taking place. Staff recorded incidents on a paper form, but these were not stored separately. This meant it was very difficult to find information on incidents that had occurred. Incident records did not show management overview or identify any lessons learnt. This meant we could not be fully confident duty of candour requirements would be met. The provider had put in place an action plan to make improvements following feedback from other stakeholders. At the time of this assessment only one identified action out of the 18 actions had been completed and 9 actions had not yet been started.

People and relatives told us they felt able to raise concerns with staff if needed. Relatives told us there was good communication and information was shared with them when needed.

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.

We observed positive relationships between people and staff. Staff interacted with people professionally and respectfully.

Systems and processes in place were not effective in ensuring safeguarding concerns were reported as required. Staff told us about safeguarding incidents, but the provider did not have a system in place to help identify when these incidents had occurred and what action had been taken in response. There was no record these concerns had been reported to the local authority as required. This meant we were not confident safeguarding concerns had been effectively identified and responded to appropriately. It also meant the provider did not have oversight or was able to monitor any restrictive practices that might occur as part of people’s care. 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) The processes in place to ensure renewals of deprivation of liberty safeguard authorisations was not robust. This had meant for one person their authorisation had expired without an application for renewal being submitted. People’s capacity to make decisions regarding their care and support had been assessed. Staff could tell us about the Mental Capacity Act and had received training in this area.

People told us they felt safe living in the service and enjoyed the relationship they had with the staff working there. One person told us how they felt comfortable talking to staff if they were worried. People were supported to make decisions around what they wanted to do and had control over their life.

Staff told us they felt able and comfortable to raise concerns with the manager and operational manager. Staff told us they had been provided with information on how to report safeguarding concerns.

Staff knew people well. They were aware of identified risks and how to support people in these areas. Staff told us they have received training, so they knew how to keep people safe. A staff member said, “The staffing team is very good, everyone knows what needs to be done, when it needs to be done, and how it needs to be done."

Risks had not always been identified and actions taken to fully address them. Whilst risk assessments were in place, they did not always provide sufficient information on how to identify and manage risks. The processes in place did not support management oversight of risks, how to identify them, and ensure risks were effectively mitigated.

We observed staff understood how to support people to manage identified risks. For example, one person needed support to eat safely and reduce the risk of choking. We observed staff following their care plan and helping them understand what they needed to do in relation to this.

People and their relatives felt staff supported them to stay safe. Relatives told us their family members were happy and settled living at the service.

People and relatives were happy with the environment in which people were living. Relatives told us staff supported people to look after their environment. Some relatives fed back that areas of the home could do with some general redecoration.

Staff also told us they felt some areas of the home could benefit from some general redecoration. The provider confirmed to us that a plan was in place to redecorate the environment and replace flooring in some bedrooms. The provider confirmed during our assessment that they had taken steps to address outstanding actions from environmental risks assessments.

Processes were not effective in identifying and addressing environmental risks. For example, the fire risk assessment dated February 2023 referred to required actions regarding fire doors and night drills that were still outstanding at the time of this assessment. The legionella risk assessment from April 2023 also referred to actions that were required to mitigate this risk, but which had not been implemented at the time of this inspection.

We observed the living environment was pleasant and well maintained. People’s rooms were personalised to them and well looked after.

Improvements were needed in the processes to ensure staff were recruited safely. We found the provider had not always identified and explored employment history in sufficient detail. They had not put in place a system to assess if potential staff had a health condition and if they required additional support to carry out their role safely. Systems were in place to ensure staff had received regular training and supervision. The training provided included specific training on supporting someone with a learning disability as well as distressed behaviour.

We observed staff knew how to support people and were responsive to their needs in a timely manner. Each person knew who was supporting them that day. We saw each person had their allocated 1 to 1 support in place.

Staff told us there were enough staff to meet people’s needs. A staff member told us, “They always have their one to one". If agency staff were needed staff told us these were the same agency staff, so they knew people and their needs. Staff told us they thought about which staff member was best to support each person as their keyworker and when supporting activities. Staff told us they received regular training and support to carry out their role. This included receiving supervision from the management team.

People and relatives were complimentary about the staff that supported them. People knew who their keyworkers were. People were supported by enough staff and received 1-1 support when required.

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.

Medicine audits were in place, errors were identified and reviewed. People had medicine care plans in place, this included guidance for when required medicines.

People received their medicines when they needed it and as prescribed. We observed staff following good medicine practice and people's medicine care plans.

Staff understood how to support people in this area. This included understanding people's preferred route of medication and timings. The manager confirmed they were in the process of updating information on medicines in people's care plans.