Liberty 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At this assessment the rating has changed to requires improvement. This meant people were not always safe and protected from avoidable harm. The service was in breach of legal regulation in relation to the safe care and treatment of people and care was not always delivered in line with people’s care plans.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were identified but were, at times, basic and over simplified. This was also identified by the provider as part of their review and assessment of the service. We discussed with the provider how identification of lessons learned and clear communication of learning to the staff team could be strengthened.

The service worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. Information packs about people’s health and medication were printed off when people needed to visit hospital. This ensured continuity of care.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. A member of the management team told us they had identified that action was needed in relation to similar incidents involving people that kept happening. A new monitoring action plan had been put in place.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care was not always delivered in line with care plans and equipment required to keep people safe was not always in place. For example, 1 person’s care plan stated they should have equipment in place to minimise the risk of falls, but this equipment was not in place. Another person’s skin integrity risk assessment indicated they were at high risk of developing pressure sores but there were no records of body maps or skin integrity checks recorded in their care plan. There were no records of when the person declined care and a recent pressure care wound audit only recorded pressure damage to the person’s legs. The person received on-going care and support from the local community nursing team. The provider was in breach of the legal regulation relating to safe care and treatment.

The service detected and controlled potential risks in the physical environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were well organised records of the checks required to monitor, maintain and ensure that the care environment was safe.

The service made sure there were qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care that met people’s individual needs. There was mixed feedback about the availability of staff. One person told us, “It [the home] is alright for care and the call bell gets answered pretty quickly,” but another person told us, “If I use the call bell, it depends on how busy they [staff] are before it gets answered.” A family member told us responses to communications could be better, “They [staff] seem to ignore messages left for them at weekends to do with [family member’s] everyday care.” We observed that staff stayed mainly in the lounge areas where people sat but some people chose to stay in their rooms which made staff deployment challenging, particularly upstairs where people had a higher level of dependency on staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. A recent infection prevention and control (IPC) inspection visit had identified some areas for improvement in relation to cleanliness of mattresses and handwashing. A member of staff told us, “There are enough of us to keep the home clean. Some days are more of a challenge because we undertake other work, such as deep cleans and flushing water sources but it’s not unmanageable and we work in a good team.”

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. The administration of medications was reviewed and audited monthly. Protocols for ‘as and when required’ (PRN) medications were clear and identified how people communicated when they were in pain.