The Cube Disability Ltd

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 provider was in the process of implementing new systems to monitor and improve the safety of the short breaks. However, these were in their infancy and required embedding into practice. Although staff received training to meet people’s needs, they lacked the experience and procedures to always know what to do if things went wrong or recognise when policies had not been followed. People could not be assured they would be cared for by staff they knew well, or that staff had all the information documented to ensure a smooth transfer to health professionals in the event of an emergency. The handover between family and staff accompanying people on their holiday was not robust enough to enable staff to understand how to meet all people’s needs whilst on holiday. Staff understood how to prevent infections and used personal protective equipment when providing personal care. The managers assessed the holiday locations for suitability and safety and staff checked the accommodation for safety during the holiday.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experiences of the planning of the holidays had not improved as the provider had not implemented all the learning from previous feedback and experiences.

The managers used their experiences of incidents to make changes to how they managed people’s moving and handling needs. For example, to source hoist equipment at the site of the holiday accommodation.

The provider had implemented new systems to record and analyse incidents and complaints, however, these were in their infancy and needed to be embedded into practice to be used to improve the service.

The provider failed to have a policy for staff to follow relating to medicines management whilst people were on short breaks. The provider failed to have a system to check staff were managing medicines safely in accordance with safe practice and existing policies.

Not all staff knew people well enough or have comprehensive documentation available to enable them to support them in the event of an emergency or transfer to health professionals.

There was no feedback from partners as people funded the holidays themselves.

The provider did not have systems to ensure staff had enough relevant documented information about people’s needs for safe transition to the holiday environment or health professionals.

People did not have confidence that staff would have the experience to know how to manage all potential incidents.

Staff told us they had received training in safeguarding and how to report any concerns. They had received support from the provider to resolve an incident to manage a person’s care safely.

The provider had systems to record and review safeguarding concerns. However, they did not always follow their processes in reviewing and analysing concerns to learn from incidents.

People relied on handover from their families and care staff to provide information to staff taking them on holiday. One person told us, “It’s difficult to explain what I need.” Their family said they had “supplied care plans, but the care staff were new, they did not know [Name] well or know their routine.”

Staff told us they had been provided with people’s care plans and documents, they said they had, “read up on individuals they didn’t know as well.”

The provider did not have robust systems to ensure people and their families were involved in managing their risks and planning their care. The provider had not allocated enough time for care staff to talk with people and their families to ensure there was a comprehensive handover of people’s needs.

People used accommodation that had been assessed as fit for purpose. People’s mobility was not always managed as planned as moving and handling equipment was not tested as working beforehand.

The managers assessed the holiday locations for suitability and safety. Staff were supplied with equipment such as first aid equipment and locked boxes for medicines. Not all moving and handling equipment had been checked before travelling to the holiday location.

The provider did not have systems to always check moving and handling equipment, but they had learnt from this and implemented additional checks for future planned holidays. The provider had systems to carry out safety checks and audits about the safety of vehicles and accommodation. For example, they ensured staff had equipment to measure the temperatures of water and food.

People did not always know the staff they went on holiday with. One person told us they would have preferred to have known the staff who were providing their personal care.

Staff deployed to each of the holidays knew at least one person from the day centres, but staff had not looked after people overnight before. One member of staff expressed concern where two staff were required to provide personal care, this left one member of staff to supervise the rest of the group. There was no evidence of planned or allocated periods for staff breaks for rest recuperation.

The provider did not always consider the impact of people receiving care from staff they did not know well. The provider did not have a system to ensure all staff received breaks during the holiday. The provider followed their recruitment policies to ensure safe recruitment of staff. Although staff received training to meet the needs of people they were taking on holiday and their competencies had been checked, staff did not always have the experience to know or the policies to follow when things went wrong.

People received care from staff that had received training in infection prevention and control and food hygiene.

Staff understood how to prevent infections and used personal protective equipment when providing personal care.

The provider had systems in place to ensure staff had the training they required to prevent infections when preparing food and providing personal care.

People could not be assured they would receive all their medicines as prescribed. People were at risk of not receiving their ‘as required medicines’ appropriately as staff did not have the required protocols to refer to. People were at risk of not receiving the medicines they required for pain and for constipation.

Staff had not followed best practice guidance as people’s medicines administration records had been handwritten and not confirmed as correct by another member of staff. Not all the medicines provided by people’s families were listed. The information about people’s medicines was incomplete and did not follow the provider’s policy. For example, the dosage of people’s medicines. People were at risk of receiving the wrong dose of medicine.

The provider failed to have a policy for staff to follow relating to medicines management whilst people were on short breaks. The provider failed to have a system to check staff were managing medicines safely in accordance with safe practice and existing policies.