Balby

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

Some improvements were required about how staff recorded accidents and incidents, including safeguarding incidents. People had robust risk assessments and associated care plans in place. However, we could not be assured staff followed these due to the concerns we found during our inspection. At the time of our inspection, the provider was implementing new systems to ensure all incidents were appropriately recorded, staff followed policies and procedures, and action was taken to keep people safe. Staff were appropriately trained and recruited safely. However, due to concerns of a closed culture amongst the staff team, the provider had implemented a new interim staff team. Medicines were not always managed safely. The service was clean and promoted safe infection, prevention and control (IPC) practices and the environment was safe.

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.

We could not be assured all accidents and incidents were recorded, and appropriate action taken to learn lessons from these. We found an incident which had not been appropriately dealt with. However, the provider took action to address this, once they were made aware.

The provider told us they had discovered only senior staff completed incident records, including body maps, meaning we could not be assured all records were accurately completed.

Improvements were required to ensure all accidents and incident were appropriately recorded, and action taken to provide people with medical treatment. The provider had taken steps to address this and was in the process of embedding new systems into practice, to ensure accidents and incidents were appropriately recorded and lessons learned moving forward.

Whilst the provider had made changes in the service to ensure people were safely cared for, some people told us they were not happy with their current support, due to staff changes. One person said, “I don’t know what the staff are called who are looking after me today.” Another person said, “I would like things to go back to normal.”

Whilst systems were in place to manage peoples care and safety, staff did not always follow the correct policies and procedures. The registered manager and staff team had not always worked in partnership with external agencies to ensure people received safe care.

Records were stored via online systems and could be easily shared with partners where required. Partners told us information was shared with them in a timely way.

We found a safeguarding incident which had not been reported to senior management, as per the providers policy. Clear systems were in place to ensure people had pre admission assessments in place and people were supported to move between different services.

At the time of our inspection there had been several incidents reported, which alleged staff did not provide safe care and treatment for people. At the time of our inspection, investigations were ongoing into these alleged incidents. The provider had taken several steps to ensure people were safe, including providing new staff, having an operations manager in the service on a day-to-day basis, conducting spot checks, well-being checks and working closely with the local authority. People we spoke with told us they felt safe; however, 1 person told us they thought staff could sometimes be sharp with them. This person said, “I had to tell the manager because some staff were telling me to clean my room in not a nice way.” Other people said, “I am safe and happy living here.” And “I like it here, it is settled. All the staff are nice to me.”

Staff told us people were safe. Comments included, “I have never seen any poor practice, if I did, I would report it immediately.” And “(Staff) have always been really professional here, never seen anything of concern.” However, a staff member told us there was often ‘banter’ between people and staff, they described comments said in a joking manner, which could be deemed as derogatory and inappropriate.

During our inspection we did not observe any poor practice. We saw staff treating people with kindness, supporting them with their care and providing activities. We also observed staff supporting one person to attend the hospital following a fall.

The provider had various systems in place to safeguard people from the risk of unsafe harm, such as policies, whistleblowing hotlines, audits, staff supervisions, staff meetings and feedback surveys for people and staff. However, these had been ineffective in identifying safeguarding concerns. We also found a safeguarding allegation which had not been reported to the local authority, we reported this to the local authority following our inspection. At the time of our inspection, we found the provider had taken immediate action to safeguard people.

Not all risks posed to people were effectively managed.

Whilst risk assessments and associated care plans were in place, staff had not always followed these. For example, a staff member had not accurately completed records relating to seeking medical treatment and there was a lack of body map records, relating to unexplained bruising. The provider had taken action to seek medical treatment and complete records following this incident.

During our inspection we did not observe any poor practice relating to staff managing risks posed to people. Staff told us they had received enough training to carry out their roles. One staff member said, “Balby is a place that provides lots of training, I carry out my duties professionally and make sure I am there for people I support.”

Staff were trained in Positive Behavioural Support (PBS) and detailed PBS plans were in place, however we could not be assured these had been followed by staff, due to concerns we found about how staff recorded incidents.

Risks posed to people from the environment were effectively managed. People told us the environment was good. One person said, “It is chilled out in here, I feel safe.” One person had raised a complaint due to concerns about the heating system and this was rectified in a timely way.

Audits and checks were undertaken by staff, to ensure that the environment remained safe for people.

We observed the environment to be clean, safe and homely. We saw equipment and furnishings which were safe for use.

At the time of our inspection the provider had implemented various systems to ensure people were safe. This included a voluntary embargo on new admissions, 3 weekly serious incident reviews, sourcing an independent external review of the service, senior managers conducting shifts in the home and well-being checks.

Due to recent concerns raised regarding the staff culture, the provider had implemented new staff into the service. Agency staff were currently being used to cover shortfalls. Whilst this change had provided enough staff to support people with their 1:1 hours, people told us this had caused them anxiety and upset. The provider had recognised this and was using the same staff for people where possible. One person said, “I don’t like the new faces, I am shy.” And another person said, “There are lots of new staff, I want the old ones back.” A relative said, “There are constantly different carers.”

Staff had received robust training, up to date policies, regular supervisions and were recruited safely. However, a closed culture had emerged within the staff team. For example, staff had been involved in monetary transactions with people who used the service. At the time of our inspection the provider was addressing these issues and conducting regular management meetings. One staff said, “With everything going on it is all a bit uneasy at work. Different people are at service each day which is unsettling for the service users. I often have to try and calm the service users due to this.”

Enough staff were in place to support people and provide them with their 1:1 support. Due to recent changes staff did not always know people well, however this would take time to embed into practice and staff had access to peoples care records which detailed people’s needs and preferences.

Following alleged concerns regarding some staff, the provider had taken steps to ensure enough staff were in place to provide support to people. Senior managers were now in place on a day-to-day basis and conducting observations of staff practice.

People were supported in a clean environment and people were involved in keeping their own spaces clean. People were seen to be clean and wearing smart clothing.

Staff told us people were kept clean. One staff said, “Most people require prompts to complete personal care, others are supported with this.” And another staff said, “Personal care is carried out regularly.”

The service was clean and tidy, Personal Protective Equipment (PPE) was available, and we saw staff wearing PPE as required. Kitchen areas were clean, and food was stored appropriately.

Systems were in place to promote safe IPC practices, including policies and procedures, cleaning schedules and IPC audits.

We could not be assured that people were given their medicines safely and in a timely manner. We checked the quantities and stocks of medicines and found some stock balances to be incorrect. This meant we could not be assured that people had received their medicines as prescribed. Instructions for medicines which should be given at specific times were not always available. Administering medicines as directed by the prescriber reduces the risk of the service user experiencing adverse effects from the medicine. Medicines were given to people in a person centred and caring way. Some people had a different routine, and this was accommodated to ensure they were kept safe. Medicines were stored safely and securely. People were seen by their GP at least annually for a routine check-up in line with national guidance.

Staff told us there was information available to them which enabled them to manage medicines safely and effectively. This ensured staff could safely administer medicines. Staff were trained in medicines administration and had competency assessments completed at least annually. Staff told us they had completed a training and induction process for medicines management. Staff and managers worked alongside prescribers to ensure that the principles of STOMP (stopping over-medication of people with a learning disability, autism or both).

There were processes in place to ensure the safe and effective use of medicines. However, audits around medicines use were completed routinely, but had not identified the areas for improvement that we found during our inspection. One Person had some medications dispensed in trays, with individual pods within the tray providing one week’s supply of medicines. The service has a 4 week cycle meaning people had 4 tray’s in stock. We found that during the two weeks prior to our inspection, colleagues had administered pods out of various trays within the cycle which could result in heightened risk of errors being made. These included two medicines used to treat psychotic episodes. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed. However, the shortfalls we found during the inspection had not been identified.