Spencefield Grange

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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

Medicines were not managed to keep people safe from harm. There was a lack of guidance for the safe administration of medicines, lack of clinical oversight and best practice was not always followed. We found the provider failed to mitigate risk for people to protect them from harm. This resulted in a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the provider could not sufficiently demonstrate processes and procedures to ensure people were protected from potential risk of abuse. This resulted in a Breach of regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the provider had failed to ensure suitably qualified, competent, skilled and experienced staff were deployed to meet people’s needs. This resulted in a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had recognised concerns around learning and culture and was in the process on making improvements, but these were not yet embedded in staff working practices at the time of this assessment. You can find more details of our concerns in the evidence category findings below.

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.

We received feedback from people and their relatives. They told us they didn’t feel listened to and incidents are not always reported, investigated, or communicated to family members. There have been several falls and we were told that staff practice does not appear to have changed following incidents.

The management team had identified failings in response to incidents and accidents and failings in duty of candor. Whilst the management team were working on improvements to this process, we found this was not yet embedded in staff working practices and so the impact on improving care was not evident. The management team acknowledged the shortfalls in the learning culture within the service and the lack of sustained improvements. The staff team also told us they felt improvements were not made following learning from accidents and incidents. Staff told us, "People are safe here unless its distressed behaviours, we are not told how to support people with behaviours. We do what we think is right to keep people safe"

Accidents and incidents were audited but were not consistently analysed or reviewed to demonstrate if lessons had been learnt and actions taken to mitigate future risk of harm for people. For example, a person had five falls over a period of seven days there was no record of an analysis being completed. Where incidents of people’s distress had been recorded, they were not supported by any post incident analysis or debrief for the person and others involved. This demonstrated a culture where lessons were not learnt to reduce the risk of harm for people.

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.

Most people we spoke to told us they feel safe. Feedback from relatives was not as positive, they did not always feel people were protected from potential harm or abuse. One relative told us, “My relative had an injury, they didn’t tell me. They had a mark on their head, I asked them how it happened, and they said they had a fall.”

Staff received training in safeguarding but were not always able to recognise safeguarding incidents and were not confident action would be taken in response to concerns. One staff member told us, "If a person falls and they got injured, I see seniors deal with it and call who they need to. Though other situations where people have an altercation and someone could become distressed, actions are not taken with that." Although the provider had safeguarding processes in place, these had not been operated effectively to keep people safe. The management team had recognised the shortfall in staff competence in understanding their responsibilities within safeguarding.

We observed consistent staff failings in identifying potential safeguarding to keep people safe. For example, a person demonstrating distressed behaviours was witnessed to be involved in an incident which caused harm to another person. Staff failed to recognise this as a safeguarding concern. They did not record or report this, and did not demonstrate their competence and understanding of their responsibilities within safeguarding to do so.

The provider’s safeguarding policies and procedures were not operated effectively to keep people safe. People’s care records were not completed accurately to provide oversight of potential safeguarding incidents. The management team had not reviewed incidents where people had left the service unsupervised and identified timely action had not been taken to keep people safe and staff had not followed measures to prevent these incidents reoccurring. Although staff had completed safeguarding training, the provider had failed to ensure staff fully understood their role and responsibilities or that these were embedded into staff working practices.

People told us they were not involved in their care planning, risk assessments or given the opportunity to take positive risks to do things that are meaningful to them. We were told, “I honestly have never heard of a care plan, they’ve never discussed my care” and “Never heard of a care plan, no reviews at all.”

Staff did not feel people were always protected from risks within the service. Staff told us, “We don’t always have enough staff on as we have a lot of people who need double staff. This means we cannot observe the people who are at high risk of falls and this puts them at risk from falling.” The manager had identified staff did not fully understand or follow measures to reduce risks and care plans did not provide the guidance or information needed to mitigate risks.

We observed consistent staff failings in identifying potential safeguarding to keep people safe. For example, a person demonstrating distressed behaviours was witnessed to be involved in an incident which caused harm to another person. Staff failed to recognise this as a safeguarding concern. They did not record or report this, and did not demonstrate their competence and understanding of their responsibilities within safeguarding to do so.

Peoples care records did not provide staff with sufficiently detailed or robust information and guidance to support the safe management, monitoring and response to health conditions including diabetes, epilepsy, skin integrity or when people were identified as at risk from poor nutrition and hydration. This meant people were at risk of harm due to a lack of safe actions to mitigate known risks.

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 and their relatives raised about staffing levels, deployment, and training. People told us staff are caring, but they had long waiting times for call bells or for staff to be free to support them. One relative told us "‘I think some staff are very good and I think some need more training, I think they way they talk to them could be better".

Staff we spoke with did not feel there were always sufficient staff to keep people safe. Staff told us, “We don’t have enough staff, we need more as we can't get round everyone with all the double ups and we have to rush, it's exhausting, especially in the afternoon" Staff also explained that some people needed supervision when they walked around to reduce risk of falling but often, they did not have staff available to do this. This meant people were put at risk of harm due to insufficient staff deployment.

Although staff were kind and caring with people, we noticed most interactions were task focused. Due to staff having to support people in their bedrooms, meant people who had been assessed as needing supervision due to high risk of falls and mobilising to keep them safe were left without observation in communal areas for long periods of time. This meant staff were unable to follow identified risks for people.

Processes and procedures in place lead to ineffective staff deployment across the service. This meant people were waiting for long periods of time for assistance which lead to a lack of interaction, stimulation and engagement. The management team had recognised there had been a lack of supervision and oversight of staff practice and competence. Leaders had introduced spot checks and competency assessments, however, these had not been effectively implemented at the time of the assessment. Staff were safely recruited, appropriate pre-employment checks had been carried out before staff started to work in the service.

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.

People felt their medications were administered safely and when needed. However, we found the guidance for staff to support people who were prescribed ‘when required’ medicines was not person centred. There were no tools to assess people who were unable to communicate when they were in pain.

Staff we spoke with lacked knowledge of some people’s complex medical conditions, so we could not be assured that staff were able to support people safely. In addition they could not always explain why they were administering certain medicines; this included misunderstanding of the purpose of medicines they were responsible for administrating. Feedback from leaders acknowledged the need to ensure staff had additional clinical training and supervision to understand their responsibilities. Staff were able to tell us how they worked with healthcare professionals to review medicines.

People received their medicines including time critical medicines on time. However, care records did not always contain accurate information for staff to support people with complex needs. For example, care records for people who were prescribed blood thinners did not have the associated risks documented. This increased the risk of staff not understanding when to escalate for medical attention. Medicines audits undertaken had failed to identify the concerns around the management of medicines we found during our assessment. This put people at risk of harm of receiving incorrect medicines or treatment.