Archived: South London Outreach Services

People were not being protected from the risks of unsuitable and inadequate nutrition, because food was not being correctly labelled once opened and some food had expired its 'use by date' but was left in the fridge alongside other food.

There were insufficient arrangements available to protect people from the risks of unsuitable equipment which was not always being fully maintained and was not operating as it was designed to. There was ambiguity amongst staff on the correct use of some of the equipment including the sensor activation alarms and when these should be switched on.

On occasions the health, safety and welfare of people using the service was not being sufficiently protected, putting people at risk of poor care and welfare due to a lack of suitably qualified, skilled and experienced staff.

We asked the provider to send us an action plan and they did.

During our unannounced visit on the 18 March 2014 we saw evidence that procedures had been put in place to ensure food was stored correctly and was within the recommended use by date.

Staff had received training on the use of equipment and checks were being made to ensure alarms were answered promptly and records kept of the reason the alarms were activated.

The provider has put in place a recruitment action plan to ensure sufficient staff were employed to meet the needs of the people who use the service.

Staff we spoke with were happy with the new procedures and said they were getting used to the additional checks they needed to make to ensure people were safe. Not all the people who used the service were able to verbalise their likes or dislikes at the new systems. But when asked they were happy for us to enter their homes, look in the fridges and cupboards and see how the alarm systems worked.

The provider wrote to us and told us they would review support for staff, improve involvement of people using the service, address risks relating to equipment and improve awareness of the complaints procedures. We returned on the 4th September and the 9th October 2013, following concerning information we received shortly after our first visit, of the 4th September. We looked at care plans and records which suggested that people required significant levels of care and support. Our inspection looked at eight outcomes.

We spoke with two people using the service but some people had complex needs meaning that it was difficult for all people to tell us about their experiences. While some improvements had been made, we found there were outstanding concerns relating to equipment and sensor alarms. We found that food had been left in a fridge-freezer beyond its 'use by date' and staffing levels were impacting on some aspects of support at the service.

Some people felt that there should be more involvement of family members as part of respecting and involving the social support of people with complex needs to avoid the risk of social isolation. One person said "some staff do not always have an understanding of how and why some clients behave in certain ways, and this can affect the quality of the interaction, communication and expectations".

We spoke with two of four relatives who described "not feeling involved or informed in the care". We asked for examples and relatives told us about several occasions where they had not been informed of important information and had not been kept up to date. We found that some people living at Maldon Road were experiencing unexplained injuries, we asked the locality manager about people's wellbeing and safety but found that not all incidents had been effectively recorded or reported.

We also learned that essential equipment used to keep people safe was often faulty, incompatible or unreliable, and there were inconsistencies in how staff managed this equipment.