The Old School House

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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 always managed to protect people from the risks associated with them. There was a lack of guidance for the safe administration of medicines, lack of clinical oversight and best practice was not always followed. This resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Care plans did not always show how people were enabled to be involved in the review of their care. People were not always supported to be independent and sometimes were unnecessarily restricted. People were supported by staff who understood their roles and responsibilities in order to protect people from abuse and the risk of avoidable harm.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives were complimentary about the service. Relatives told us they were positive about how their loved ones transitioned into the service and felt they settled in well. We were told, “Staff managed [Name] transition really well and [Name] seemed at ease very quickly”. Relatives told us that good quality care was delivered within the service. However, there was no evidence to demonstrate further evaluation for people that may have gained more independence from transitioning to different services.

Staff used personalised approaches to support people when transitioning into the service and described how they used information about people to plan for their likes and dislikes. However, there was a lack of understanding around setting ambitious goals with people to increase their independence and potential to transition to other more independent settings.

The local authority provided feedback following their audit of the service. Their findings included that people’s records did not always evidence the involvement of people and their families in the development of their care and support.

People’s needs were reviewed prior to admission to the service and information was used to form the basis of people’s care plans. These were reviewed and developed once people began to use the service to ensure the care and support provided met people’s needs. However, care plans did not clearly evidence how people were enabled to have a voice and be involved in the review of their care. There was limited evidence of external agencies or families involvement in review of people’s care needs. Care plans did not clearly demonstrate if or how people and those important to them were enabled to identify personal goals and aspirations, in particular, with a view to moving on to more independent living or exploring a particular life style choice.

People told us they felt safe at the service. The relatives we spoke to all felt their loved ones were safe and well cared for at the service. We were told, “I have absolute faith and trust in the staff, I know [Name] is very safe there”. Another family member told us, "[Name] comes home every fortnight & I think we would struggle for them to go back if they didn’t feel safe there but [Name] is always happy to wave us off.”

Staff knew how to keep people safe from harm or abuse and there were up to date procedures in place for them to follow. One staff member said, “People are safe because we know the risks they face and make sure we stay with them where we need to. We look for changes in a person’s gestures or responses which can indicate if something is wrong.” However, further work was needed to ensure staff fully understood any conditions attached to legal authorisations where a person was deprived of their liberty (DoLS).

We observed people appeared to be happy, comfortable and relaxed with staff. However, we were not assured that staff always demonstrated a good understanding of the individual needs, choices and preferences for people. For example, we saw that people did not have a choice of where they spent their time. 2 people had rooms downstairs but they were taken to the lounge upstairs, staff could not tell us why this was. People could not take themselves to their rooms from the upstairs lounge themselves without staff assistance. Staff told us, "people wouldn't want to go downstairs, they stay up here all day, that what they have always done."

The provider had robust policies in place to provide guidance for staff and managers. However, we observed that these were not always fully understood or applied consistently through staff working practices. The provider had systems and processes to record, review and analyse accidents and incidents. We reviewed notifications and records of incidents which had been analysed by the registered manager and action had been taken to mitigate risk. Records showed there had been no reportable safeguarding incidents.

People did not always have their independence supported by staff. For example, we saw a person discouraged from spending time in their room and redirected to the lounge. We were not assured that people were fully involved with the development of plans for their care and support. The service had introduced communication packs designed to assist people in communicating their needs. They included key information about people's needs and also a favourite activity or sensory tool which they would find comforting, however it was not clear as to how these were being used within the service.

Staff understood their roles and responsibilities and the actions needed to keep people safe. Although staff felt confident in managing risks, they had not received the correct training to manage risks relating to complex health care tasks. The registered manager acknowledged there was a lack of training for such needs and also a lack of oversight to ensure regular staff competencies were assessed.

Staff were observed to support people in a respectful way. However, in some instances, staff management of risk potentially placed unnecessary restrictions on people. We found staff were not following a specific emergency health protocol which outlined the measures to take in response to a person's health condition. The provider’s representative told us they would immediately address this with staff and ensure a protocol was adhered to. We saw one person who liked to walk freely around the home was consistently redirected by staff to their bedroom.

Risks to people had been assessed and plans were in place to mitigate such risks. However, staff were not consistently following measures in place. People’s care plans did not always record best interest decisions. People were not supported with positive risk taking. One person was at risk of having their freedom unnecessarily restricted due to staff not following care and support plans. The service did not follow best practice around positive behaviour support strategies. For example, not all staff were trained in positive behaviour support and incidents of distress were not recorded or reviewed. The provider had identified this prior to our assessment and was arranging support including PBS training and guidance. The provider has policies and processes in place for positive behaviour support but these had not been implemented effectively in the service. This meant managers and staff did not have appropriate guidance in place to ensure people were supported safely.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

There was a consistent staff base who knew people well and contributed to a friendly and supportive atmosphere within the service. No concerns were expressed by family members in relation to staffing levels. One relative told us, “There are always plenty of staff about.”

Staff felt supported in their roles and were able to gain advice and guidance when required. Staff told us they completed a range of training that gave them the skills and knowledge required to meet people’s needs and keep them safe. However, we found staff did not always follow guidance or have clear direction in order to support people with distressed behaviours and delegated health care tasks. The management team accepted there was a lack of training and competency within the staff team to ensure these tasks could be completed safely.

We saw sufficient staff were deployed to meet people’s needs and keep them safe. Staff had time to spend with people outside of delivering care, talking and interacting with them.

Staff training required further development to ensure robust oversight and assessment of competence to allow staff to remain safe to undertake specific delegated healthcare tasks. Staff felt supported and confident in their roles. Regular competency checks were undertaken to ensure staff remained safe and competent to undertake delegated healthcare tasks, such as enteral feeding (feeding through a tube directly into the stomach) and rescue medicines to be administered in the event of a health crisis. However, checks were not undertaken by a clinically trained staff member. There was a potential risk that competencies were not accurately assessed. Although we found no evidence people were harmed as a result of this, we did find concerns around medicines administered through enteral methods which would have been identified by a clinically trained assessor. The provider had not established clear protocols with external agencies for specific delegated healthcare tasks.

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.

Relatives told us they were confident their loved ones received the medicines they needed and were assured staff worked closely with other healthcare professionals when required. One relative said, "Oh yes, [Name] is on medication and [staff] always keep me updated”.

Staff told us they felt confident when administering medicines. However, the management team acknowledged staff did not have the correct training, competencies and oversight to ensure the safe administration of medicines both for emergencies and via an enteral method. This meant people were at risk of not having their medicines administered safely.

Records evidenced people received their medicines as prescribed. All medicines were stored securely, however the service did not have a secure way of moving medicines throughout the service. People who had been prescribed medicines on a when required basis (PRN) had written plans in place however, the information included in some plans was not sufficient to inform the staff of how and when it was appropriate to administer these medicines. The service had additional documents to record the reasons and outcomes for PRN medicines. These documents were not always completed to provide evidence that demonstrated the need for these medicines and whether the medicines were effective. Where people needed to have their medicines administered directly into their stomach through a tube, we found there were no robust clinical protocols in place to inform staff on how to prepare and administer these medicines safely. A risk assessment for a high risk drug had not been carried out.