Greenways

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

The principles of RSRCRC were not met as the model of care provided did not allow people to live empowered lives with maximum choice. The risks associated with people’s care were not always being managed in a safe way and there was not always sufficient staff to support people in a safe way. Staff had been recruited safely and whilst there needed to be some improvement in the managements of medicines, people received their medicines as prescribed. During our assessment of this key question, we found concerns around the management of people's incidents and accidents and the risk associated with their care which resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found concerns around there being insufficient, suitably trained staff deployed at the service which resulted in a breach of Regulation 18. We found people were not always being protected from the risk of abuse which resulted in a breach of Regulation 13. You can find more details of our concerns in the evidence category findings be

This service scored 44 (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 they would complete forms when incidents occurred however this was not always happening in practice. One member of staff told us, “If it is an injury, they will start an incident report and discuss with them. They we will have a meeting to discuss what caused it and learn from it.” However, they said, “The discussion is mostly not recorded but the incident is.” The registered manager infrequently attended general staff meetings where this would have been an opportunity to understand the day-to-day incidents within the service.

One relative told us their loved one had developed a particular behaviour but found that sufficient action had not been taken by staff to look into why this may be happening. Other relatives told us they were kept informed when there had been an incident.

There was a lack of analysis of people’s heightened states of anxiety to look for trends and themes to reduce further risks to people. For example, we were told 1 person was triggered by another person they lived with. Although we saw from their incident forms, there were times the incident had been recorded that the other person was the trigger, there were other incidents where this was not the case and there was no evidence this had been reviewed and analysed to look at the possible cause. Staff were not consistently completing incident forms for 1 person when they had a seizure. According to their care plan, staff were to call an ambulance if the seizure lasted for more than 5 mins. 1 incident form recorded the seizure lasting for longer than this, yet staff did not call an ambulance and instead called 111. Staff were not always completing an incident form when a person was having high levels of anxiety. We noted there were 14 days in June 2023 where high levels of anxiety were recorded in daily notes for 1 person, yet only 2 ‘behaviour’ incident records were completed.

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.

The provider failed to ensure people were protected from emotional and psychological abuse. For example, we saw from their care notes 1 person's activities had been cancelled or told they were unable to see their [family member] due to their ‘behaviour’. There was no guidance in the person’s ‘Positive Behaviour Support Plan’ that stated that activities should be restricted when the person experienced heightened emotions. The provider failed to ensure people were always protected from the risk of neglect. We found 1 person was secured into their living space every night for more than 12 hours a day. There was no ability for staff to visually monitor the person’s wellbeing.

Staff told us they would report any safeguarding concerns. One member of staff said, “Safeguarding is to make sure residents are free from abuse and neglect. If we say anything that is abuse or neglect, we have to blow the whistle as soon as possible.” However, staff did not recognise that 1 person, who frequently self harmed may be a safeguarding concern.

One person fed back to us their concerns about a member of staff. Despite the registered manager telling us this was normal behaviour for the person to say this, we found sufficient action had not been taken to address this with the person. There was also nothing in the person’s care plan to state this behaviour was normal for them. This meant there was a risk their concerns may be dismissed rather than taken seriously. Relatives told us they felt their loved ones were safe. One told us, “We have no concerns” whilst another said, “I do feel (person) is safe.”

There was discussion at each staff meeting around safeguarding procedures. However we found there was a lack of understanding by the leadership team of when things needed to be reported to the local authority. Staff received training and there were policies in place.

The risks around people’s care were not always being managed in a safe way. For example, 1 person needed staff to sit with them when they ate as they were at risk of choking due to them eating quickly. On day 1 of the visit, we saw the person eating their food very quickly and staff were not encouraging them to slow down. On day 2 of the visit a member of staff told us they left the person on their own that day to eat their meal which placed the person at further risk. There were no assessments in place around the risk of them choking.

Although relatives did not raise concerns, we found the risks associated with people’s care was not always managed in a safe way. We did not see evidence that people were involved in the management of risks.

We were made aware of 2 people that were taken for long local walks down busy farm roads with no public foot paths. One person also listened to their electronic tablet whilst doing this. This was an added risk; they may not hear oncoming traffic. There was a risk assessment which was updated after we raised this concern, but only updated to say person must wear high visibility jacket. There was nothing in the risk assessment around the safety of the road. We were told another person at times required a wheelchair due to mobility however there was no risk assessment in relation to this or any moving and handling care plan. We found 1 persons care plan for ‘Restrictive physical intervention’ was generic and no detail of how person may present and how staff should respond. The care plan stated “There is no agreed Restrictive physical intervention agreed to be used with X.” This meant that staff may not provide the most appropriate support to the person when they were at a heightened state of anxiety.

Staff had a mixed response around their understanding of how to manage the risk to people. One member of staff told us they were involved in the review of people’s risk assessments. They said, “I do the risk assessments, [Quality manager] does, [Registered manager] does. It depends on the risk that comes across.” Staff we spoke with were not always aware of the risks associated with people’s care.

We found elements of risks to the environment were not always managed in a safe way. One person was secured into their living space each evening. This included them having access to their own bathroom. However, we found the radiator in the bathroom was very hot to touch and yet this had not been assessed around the risk of burning. The person also had large blocks of wood nailed across their windows however this adaptation had not been risk assessed to ensure it was safe. Staff were routinely keeping 1 person’s bedroom door open with a cardboard wedge as the latch on the door had broken. A wedge prevents a door from closing, which means fire can spread, putting people in danger. A member of staff told us they knew they should not be doing this, yet they had not reported the broken latch to management.

There were audits in place to check the safety of equipment and the building. However, this was not effective in identifying the concerns we found. In the event of an emergency such as a fire each person had a personal evacuation plan. These were left in the office and could be accessed quickly and easily if needed.

Relatives felt the home was a secure environment for their loved ones. One relative told us their loved one had moved in to the main house due to their sensory impairment. They said their loved one was able to navigate the home in a safe way. However, we found there were elements to the environment that were not always safe for people.

The deputy manager told us they did health and safety audits of the environment. Staff were able to tell us how they would evacuate people in the event of a fire.

Staff told us they did not have a concern they did not have formal breaks. Comments from staff were there were sufficient staff to manage the service in a safe way. One member of staff said, “I do think there are enough staff, the amount of experienced staff here, they know what they are doing, and we get used to the client.” Another told us, “They are quite long shifts which I really enjoy as I do most of the cooking. I do lunch and dinner.” This member of staff was also supposed to be allocated to a person as their one-to-one staff, but their time was taken up with preparing meals. Staff told us they received supervisions and found these useful. One member of staff said, “find them useful, they will let you know if you need any more training, need to update, sometimes in the kitchen if I am doing right or wrong or a good menu. I try different menus; I will suggest new menu ideas.”

Staff working hours were at times unsafe. The registered manager told us, and we confirmed from rotas, staff were doing 15 hours shifts with no breaks, 3 days in a row and at times that member of staff was also the sleep-in member of staff. The registered manager told us they were introducing staff breaks but at the time of the second visit this had still not been implemented. This risked staff being fatigued and having no time to decompress. We saw from rotas staff were at times working long hours in a week. For example, 1 member of staff worked 86 hours and also rotered to be the ‘sleep’ in on 2 nights. There were times other staff worked 6 days in a row of 15-hour shifts totalling 90 hours work in that week. This was particularly concerning given there were no formal breaks and working in, at times, a high-pressure environment given what we were told about people’s high levels of anxiety where staff needed to provide support. Although the majority of staff had completed all of their mandatory training and were having supervisions with the manager, this was not effective in identifying shortfalls in the effectiveness of care being provided. All staff had undertaken enhanced criminal records checks before commencing work and references had been appropriately sought from previous employers or character references.

There was mixed feedback from relatives on whether there were sufficient staff to support people. Comments included, “There is enough staff, they look after (person) well”, “I think there is enough staff, they always seem to be doing things with (person) and other residents” and “I think sometimes there isn’t enough staff because they are all supposed to have their own carers.”

The provider was failing to ensure there were sufficient numbers of qualified staff to ensure people’s safety. For example, according to their care plan, 1 person was required to have 2 staff with them when they went out. However, the registered manager confirmed with us they were unable to provide 2 staff with the person on walks. We saw from the person’s incident forms the person had instances of heightened levels of anxiety when on the walks and only 1 member of staff was present. The registered manager told us at night there was only 1 member of waking staff and 1 sleep in. The registered manager told us staff levels were unsafe due to the unpredictable episodes of anxiety displayed by 1 person. Despite knowing this, steps had not been taken to increase the waking staff levels at night.

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.

Whilst people received their medicine as prescribed, there were some elements to the management of medicines that were not robust. For example, we found 1 person’s medicine count was not correct and there were 50 tablets instead of 52. We observed staff discuss this and recalled 1 dose was wasted as the person refused but another dose was then given. However, staff had not recorded this. When I pointed this out, a member of staff stuck a sticker on top of the Medicine Administration Record (MAR) rather than recording the error on the back. The guidance for staff around the ‘as and when’ medicine was not always accurate in relation to why they may need the medicine. For example, the same guidance for 1 persons ‘as and when’ anti-psychotic medicine had the same wording for the person’s ‘as and when’ paracetamol. This meant staff may give the person ‘as and when’ medicine when it was not required. Other areas of the management of medicines were undertaken in a safe way. All MAR had a recent photograph of the person for ease of identification. Most of the medicines were ordered in blister packs in a four weekly cycle which reduced the risks of mistakes happening.

Relatives did not raise any concerns around the management of people’s medicines. There was a risk however people were not receiving medicines when needed as guidance for 'as and when' medicine was not clear.

The registered manager and staff were not recording all of people’s controlled medicines in a CD book which is safe practice to do. This was despite the providers quality assurance manager raising this as a concern in an audit in January 2023. The registered manager told us they did not do this for controlled medicines that were only given ‘as and when.’ However, they were unable to explain their rationale for this.