Jane 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

We have identified one breach of legal regulations. Management oversight of risk and care records was not robust. There was a failure to identify and mitigate the risks we identified during our assessment. However, care plans guided safe care. There were enough staff to support people safely. Safeguarding procedures protected people from abuse and avoidable harm. Medicines were managed safely.

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.

Learning from incidents and accidents was used to improve outcomes for people. A consistent approach to positive behaviour support had reduced the need for some restrictive practices, such as door locks. A person’s environment had been adapted to mitigate risks and behaviours associated with their proximity to other people. This had positive outcome. The person felt safe, and their anxieties were reduced.

There were opportunities for staff and leaders to learn lessons and improve outcomes for people. Staff reported accidents and incidents appropriately and told us, “We discuss incidents at team meetings.” and “A debriefing is required after all incidents.” Staff told us they found this beneficial as it provided an opportunity to share their experiences and learning. Managers told us they used shared learning to improve people’s care experiences and to drive service improvements and safety.

Processes were in place to ensure accidents and incidents were appropriately reported and monitored. Monthly review meetings analysed incidents relating to people’s behaviour. The meetings provided an opportunity to understand the reason behind the behaviour, such as triggers or communication needs. Meeting minutes demonstrated lessons arising from these meetings were shared and acted upon. Learning was used to support people in a more appropriate and safer way.

People were supported with health appointments. Records confirmed that people had access to services including GP’s, opticians and dentists. Key workers attended external appointments with people. There were clear guidelines and strategies in place regarding any procedures which may increase a person's anxiety. For example, one person’s health action plan explained how they did not tolerate needles and advised on alternative strategies to support them.

Staff had an awareness of the risks to people relating to their health and care. Senior staff made regular referrals to health and social care services and supported people to attend meetings with healthcare professionals. Staff told us there were regular opportunities to discuss changes in people’s care and well-being needs. Information was used to inform people’s care records and pathways to ensure continuity of care.

We did not receive any specific feedback from professionals who worked at the service during this assessment about safe systems, pathways, and transitions.

Systems were in place to enable smooth transitions between services when required. People had health action plans and hospital passports. Some information contained within hospital passports could not be relied upon as being up to date or accurate. Following our feedback the registered manager provided assurances of a review of all hospital passports for accuracy of information.

People were safe and protected from harm. People’s environments had been adapted to keep them safe and they were supported by trained staff. People received visitors to their home and relatives told us they were able to visit regularly including unplanned. Relatives had no concerns about their loved one’s safety. They told us staff knew people well and they observed friendly interactions.

Staff knew people well and knew how to raise concerns they might have about people’s safety or wellbeing. Staff knew how to report concerns to appropriate agencies such as safeguarding adults or the police. Staff we spoke with did not have any concerns but said if they did, they would go to the registered manager or use the whistleblowing policy. Staff were confident they would be listened to.

We saw people were comfortable approaching staff when they needed support. Staff spoke to people in a respectful way, and we observed positive engagement and interactions between staff and people.

Staff had received training in how to safeguard people. They were knowledgeable about the types of abuse and how to recognise these. The service had a safeguarding policy; this was available to all staff as guidance for dealing with any such concerns. Information about keeping safe was available to people in accessible formats.

People were not always supported by robust risk management. For example, a person who was prescribed medicines to manage seizures did not have a care plan or risk assessment in place to support their epilepsy safely. There was no reference to the persons epilepsy, or prescribed emergency seizure medicines in their other care plans, including those for swimming, bathing, and keeping safe. It is acknowledged there had been no impact to the person and epilepsy management plans were implemented following our feedback. Where risks to people had been assessed risk management plans considered safe staffing requirements as well as the environment, equipment, and behaviour. This enabled people to be safe in their own home and safely take part in things they enjoyed such as swimming, bowling, cinema, and horse-riding.

There was a failure by senior staff to ensure all risks to people were considered or shared. Care staff told us they were not involved in assessing risks to people. They relied on their own knowledge and people’s care records to support people in a safe way. Staff described people as “Complex” and “Challenging,” and said they received training to support people’s safely.

We observed Staffing was in line with people’s risk management plans. Staff understood people’s communication including facial and body language cues. Staff were competent in recognising behaviour triggers and implementing people’s positive behaviour plans.

Risk management processes were not consistently applied to identify and mitigate risks. Lessons were learnt from incidents and used to improve safety and people’s care experiences. Safety decisions made in people’s best interests followed proper guidance.

People were supported in bespoke living environments designed to improve their quality of life and reduce behaviours that challenge. Some environments were locked for periods of time when people’s behaviour placed them or others at risk of harm. Two people had personal spaces they could access independently with walls and floors cladded in materials to keep them safe. People could not be assured their wellbeing was being safely monitored when using these areas. Lawful restrictions were in place to keep people safe, including CCTV and locked gates and doors. People’s accommodation supported positive interactions and provided opportunities for meaningful activities and choice. A person who liked water had a jacuzzi bath and their own outdoor hot tub. Another person was able to safely prepare snacks in their home.

Staff were not recording regular checks on people when restrictive interventions were being used. Consideration had not been given to the importance of these for people’s safety and wellbeing. Staff told us people had their own spaces which were important to them. For example, one person had their own office. They liked to “Write things down, to keep a record of event, and to draw pictures.” This reduced the persons anxiety. We saw there were sticky notes on the walls with important dates and information, for example their keyworkers holiday dates. Staff told us people used the garden constantly for exercise, trampoline, bike riding and ball games.

The environment had been modified in line with people’s risk assessments to keep them safe. We observed some equipment in these areas not to be working as they should be. For example, on one visit staff were unable to access monitoring equipment in place to keep people safe. In one person’s annex there was no working light in an area with no windows. Some restrictions were in place such as window restrictors and keypads. These restrictions were lawful and kept people safe from avoidable harm. For some people keypads did not restrict their freedom of movement as they were able to use them independently. On all three visits to Jane House, we observed people using the garden independently with staff providing observation and engagement as appropriate.

When restrictive practices had been used information recorded lacked detail and did not evidence wellbeing checks or record times. This meant the provider could not be assured these interventions were being used safely and appropriately. There was a regular program of audits and safety checks to ensure the environment was safe and free from hazards. Risk management processes were in place for emergency situations including fire safety assessments and individual personal emergency evacuation plans for people (PEEP).

There were enough staff to support people well. People were supported by a consistent team of skilled staff who knew people, their needs, and preferences. Relatives told us staffing ratios were maintained. A relative said, “There is always a carer who knows(name) well.” People’s assessed staffing ratios were provided. This enabled people to participate in activities safely and receive consistent and timely approaches to emotional or behavioural needs. People who had cars were able to use these regularly because they were supported by staff who could drive.

Staff told us there were always enough staff to provide safe care. Staff covered gaps in the rota to minimise the need for agency staff. Staff we spoke with were positive about training available to them. They said, “The training is really good,” and gave them the skills and knowledge needed to support people safely and well. They told us they received a comprehensive induction and training. This included approved training to support people with a learning disability and autistic people.

Throughout our assessment there were enough staff to meet people’s needs safely. Staffing levels reflected the planned rota. There was enough staff to support people with their planned activities safely. This included observed activities away from Jane House. We saw positive engagement and interactions between people and staff throughout the assessment.

Safe employment processes protected people from the recruitment of unsuitable staff. References were obtained and appropriate checks were made to ensure staff were safe to work with people and authorised to work in the UK. The rota reflected safe staffing ratios were consistently maintained. There was a comprehensive programme of training to ensure staff had the skills and knowledge to undertake their role.

People were protected from the risk of infection. People were supported by staff who followed infection, prevention, and control (IPC) processes.

Staff told us they had received training in food hygiene and IPC. They were knowledgeable about how to prevent the spread of infections and the need to use personal protective equipment (PPE) which they said was readily available to them. The registered manager knew what to do in an infection outbreak.

We observed some of the de-escalation areas and bathrooms needed to be more robustly sanitised. We spoke with the senior staff on duty and cleaning was actioned immediately. We saw staff were able to access aprons and gloves and these were used appropriately throughout our visits. Staff encouraged and assisted people with hand hygiene appropriately, for example after using the toilet and prior to meals.

There was an up-to-date IPC policy which included staff training and IPC audits. The audits had not identified the sanitation concerns we observed during the assessment. Processes were in place to report and record infection outbreaks. The registered manager told us that no concerns had been raised at the services last Food Standards Agency check. Suitable procedures were in place to ensure food preparation and storage met national guidance.

People’s medicines were stored and administered safely. People had person centred medicine plans which enabled them to receive their medicines safely and in line with their preferences. Medicine administration records (MAR) were in place to ensure people received their medicines as prescribed. There were systems in place that ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. People had regular medicine reviews to ensure their medicines were current and required.

Staff administered medicines safely. This was supported by training and observed practice competency checks. Staff told us they felt confident to administer medicines. Staff were knowledgeable of people’s individual needs, including when to give ‘as and when required’ (PRN) medicines and when to seek additional medical support.

The providers policies supported the safe management of medicines. There were processes for ordering, storing and disposal of medicines and safety checks to ensure medicines received reflected the prescriber’s instructions. There were clear protocols for administering PRN medicines and regular medicine checks and audits. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism, or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles.