Bobbins

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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 found 3 breaches of regulation. People were not being kept safe from potential abuse, the use of restrictive practices or risks being assessed. Staff had not received adequate training to safely support people. Medicines were not always managed safely. We raised our concerns with the provider during this assessment and they took immediate action to make improvements. For example, there was a focus on improving systems and staff training. This had already led to a reduction in the use of restrictive practices. We will continue to monitor the service to ensure the changes have been sustained.

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.

People were supported by staff who lacked understanding on ways to keep them safe. Staff did not always understand how to speak to people at times of distress in a respectful way. This included protecting people from potential abuse including inappropriate use of restrictive practices. However, people appeared calmer in the presence of some staff by the second day.

Staff had not received or been offered sufficient training to be able to understand to recognise potential abuse or use of restrictive practices. Staff did not have training to identify why an incident occurred and what could be changed to prevent further occurrences. However, by the second site visit some staff already appeared more confident although this was not consistent.

People appeared to not always be comfortable in staff presence. For example, becoming distressed when staff stood over them, rather than providing space. Staff were unaware they could be escalating people’s distress and lacked an understanding how to support people effectively. However, by the second site visit we observed a calmer atmosphere and people appeared to be experiencing reduced times of distress.

Systems were not in place to keep people safe or consistently identify potential abuse, including use of restrictive practices. For example, the management and provider were not identifying incident records which were restrictive practice or patterns of bruising. Systems had not identified We raised our concerns with the provider who told us they would review processes around restrictive practices and issues identified. With considerable support, improvements had been made by the second site visit.

People were not always involved in managing their risks. Staff involved people's relatives with managing risks.

Staff had mixed understanding of how to support people to mitigate risks to them. For example, some staff talked about people in a punitive way when they became distressed rather than recognising their individual needs and communication. We raised this with the provider who assured us they would take action. With considerable input, by the second site visit staff were beginning to demonstrate understanding their actions could increase risks to people.

People were not always supported in a way that was respectful and mitigated risks to them. For example, not recognising taking distressed people in a car with others could increase risks. This led to an increase in people's distress when communicating their needs. We raised this with the provider who assured us they would take action to improve staff knowledge and understanding. With considerable input from others, by the second site visit improvements were starting to be seen.

Staff were not always given enough detail to ensure they provided consistent support when managing risks to people. Inconsistencies were found in care plans and sometimes it was not clear how staff should support people to mitigate the identified risks. For example, when people had specific needs around eating and drinking there was mixed guidance which staff were not familiar with. Limited or mixed detail about how people should be supported proactively to prevent distress was in place. We raised our concerns with the provider, and found by the end of our assessment, the management team had begun reviewing care plans to make the required improvements in line with best practice.

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

People were not always comfortable around staff when they were supported in a punitive way. However, relatives felt people were supported by kind and caring staff. People clearly had positive relationships with some staff.

Staff told us they had not had all the training and skills required to keep people safe and meet their needs. We raised our concerns with the provider who took action with considerable support to make improvements to staff knowledge and training. By the second site visit we started to see staff demonstrate more knowledge.

We observed staff did not always understand people’s needs and this caused increased distress at times. For example, some staff did not recognise when they needed to give people space which escalated a situation rather than preventing it. This meant staff had not received effective training or knew people well.

Systems were not in place to ensure staff were effectively trained or had been recruited safely. For example, staff had not received training about how to proactively support people who became distressed. In addition, not all staff were recruited safely and in line with the Health and Social Care Act 2008 regulations. This was because there were gaps in staff employment records. We raised our concerns with the provider and they immediately started to make improvements.

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.

Systems were not always effective to safely manage medicines. Although, the provider had identified some of the issues, prior to our assessment they had failed to identify all the concerns we found. Processes to store medicines were ineffective because adequate temperatures were not monitored. This people at risk of harm. We raised these concerns with the provider, who took immediate action to improve the safe storage of medicines. This included purchasing a specialist piece of equipment to monitor the storage of medicines.