Northern Healthcare Head Office

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 service had robust care planning processes in place, with people involved in their own support planning. Plans included promoting people’s safety, physical health, mental health and well-being. Individual risks were identified for people and measures were in place. Safety plans and coping strategies were outlined for individuals. Care plans and risk assessments were reviewed and updated when needed. We found systems and processes in place to help protect people from abuse; potential safeguarding issues for people receiving a regulated activity were raised with the relevant host authority. On 2 occasions, CQC were not notified about safeguarding concerns, despite the provider requirement to do so. The service rectified this immediately. Staff were aware of who to report safeguarding concerns to. The management team were proactive in addressing any actions arising from safeguarding meetings and ensured good outcomes from lessons learned. The service shared findings with staff in staff safety huddles/meetings and supervisions. Effective recruitment processes were in place, with support and oversight provided to the service managers from a team with recruitment/HR functions based at Head Office. Some feedback obtained from relatives indicated that there was high staff turnover. Staff received appropriate training and supervision, with positive feedback. Management undertook audits of staff files and put risk assessments in place where required. Medicines management processes were in place, including appropriate risk assessments in relation to people self-administering medication. Storage of medicines was inside a nominated clinical room, inside a locked cabinet. Whilst premises are the responsibility of the landlord, processes were in place to ensure repairs and maintenance required on sites were reported and rectified. The 2 sites visited were fit for purpose.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People benefited from the learning culture that existed and was promoted within the service. Any accidents, incidents or complaints were investigated and reported. People were encouraged to speak up about any concerns or complaints so these could be put right, and the service could improve.

Staff were aware of safeguarding and whistleblowing procedures. Staff told us they were encouraged to speak up about any concerns, for example in meetings, supervision, safety huddles and handovers. Staff could also approach line managers and senior managers direct if they preferred.

Feedback we received from partners was positive. Partners were assured the provider had robust processes in place and took appropriate action following any safeguarding incidents, accidents or complaints. The service could demonstrate lessons were learned and were communicated with staff.

Processes and policies were in place to aid managers identify any shortfalls in the service and to help demonstrate lessons learned. Following any incidents or accidents a root cause analysis tool was available to pinpoint any service delivery issues. Lessons learned and any subsequent changes in practice were communicated to staff. These included a monthly communication that reminded staff or highlighted good practice in relation to elements of care and support, such as medication, incident reporting and record keeping. Following a delay in identifying and raising a safeguarding, lessons had been learned by the provider. Governance in relation to safeguarding had been made more effective to reduce the risk of delayed reporting from reoccurring.

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.

People had capacity and were able to live their own daily lives. People could choose what to do, either with or without staff support. People were encouraged to take positive risks and we saw examples of these. Appropriate action had been taken to ensure people remained safe, for example risk assessments and safety checklists were in place.

Staff told us they received regular safeguarding training. This meant staff could recognise different types of abuse, the actions required to prevent it and what they should do if they suspected it. They knew how to report concerns both to the management team and externally to organisations such as the local authority, the host safeguarding team and to the Care Quality Commission (CQC).

Two incidents had recently been referred to the host safeguarding authority for people receiving a regulated activity. These had not been shared with CQC. These were submitted retrospectively, with no further actions warranted.

Safeguarding concerns were reported to the host authority safeguarding team and to commissioning authorities, where different. Potential safeguarding events were discussed with staff in safety huddles, supervision and team meetings to plan if anything could be done differently in the future. Safeguarding procedures were reviewed and accidents and incidents were analysed. Plans were put in place to reduce risks to people and improve their safety. Leaders reviewed all safeguarding concerns and shared the lessons learned from them across the organisation.

We were unable to speak with people who used the service directly about how risks were managed, however we saw that they remained safe being supported by the staff team. People’s risks were assessed and mitigated, enabling them to lead independent lives, when safe to do so. People were supported to take positive risks when it was judged safe to do so. One person had joined an organised group event held some distance away and had travelled solo to get there. Work had been done to ensure they were confident in doing this and there was 24/7 support over the telephone if this was required.

Staff were provided with guidance about how to support people in line with their assessed risks. Staff were confident in explaining what people’s support needs were and explained ways they best supported people to ensure they remained safe. Staff told us they used their training to support people living with a mental health condition, and described how people they supported were kept safe. People, their relatives and where necessary, healthcare professionals participated in drawing up risk assessments and electronic records we looked at supported this.

We observed during our site visits people were kept safe. There were enough staff available to support people in line with identified risks. Staff made sure people had the right level of support whenever they left the service if this was a commissioned element of care.

Staff were provided with guidance about how to support people in line with their assessed risks. Staff were confident in explaining what people’s support needs were and explained ways they best supported people to ensure they remained safe. Staff told us they used their training to support people living with a mental health condition, learning disability and autism. They described how people they supported were kept safe. People, their relatives and where necessary, healthcare professionals participated in drawing up risk assessments and electronic records we looked at supported this.

People signed up to a tenancy with a housing provider independent of the provider. They had their own private room and shared other communal facilities, such as lounges, kitchens and bathrooms. We received negative feedback from a relative regarding a utilities billing issue which the provider had raised with the inspector. The provider was trying to resolve the issue, however it had resulted in some distress for people and families due to the debts that had accrued.

Staff told us some people received support or were prompted by staff to keep their own rooms clean and tidy, others were independent with this regard. Staff were aware of any specific support people might need in the event of an emergency evacuation, with information documented in Personal emergency evacuation plans (PEEPs). These were updated following any changes in need, for example a deterioration in mobility.

Communal areas we saw were clean, tidy and fit for purpose. The provider took responsibility for checks on the premises in relation to fire alarm tests and fire evacuation; we saw records that demonstrated staff carried out walk rounds of buildings to check people remained safe.

The service liaised with housing providers to ensure private rooms, communal areas and buildings remained safe and fit for purpose. Any concerns or required repairs regarding premises were escalated to the housing provider in a timely manner. Tools such as an electronic reporting system and a service action plan assisted service managers and the registered manager to track and monitor progress with these. External contractors and housing providers contributed in ensuring people’s health and safety was maintained.

Although we saw that staffing levels were in line with identified needs and use of agency staff was minimal, one relative provided negative feedback. The relative told us that they felt the staff team wasn't consistent or adequately trained. People were able to leave the service independently or with support from staff, depending on their assessed need. There was evidence in the form of pictures, of people taking part in activities or events. People were able to go on holiday, swimming, attend festivals, go for meals out and take part in leisure activities.

Staff we spoke with had positive things to say about staffing levels and the training on offer. The staff team were consistent and there was minimal use of agency staff. The management team completed supervisions and meetings with staff to discuss training and any support needs they had. Staff we spoke with felt well supported and listened to. All staff had undertaken bespoke training around mental health conditions during Mental Health awareness week, with an experienced external trainer.

Management teams both on and off site demonstrated the tools and processes in place to ensure staffing levels were adequate to meet people’s needs and were regularly reviewed. There were effective procedures in place to help ensure new staff were suitable for their job roles at the service. Experienced recruitment staff coordinated an ongoing staff recruitment campaign to maintain appropriate staffing levels across each of the supported living services. The provider undertook checks of potential staff prior to their recruitment to ensure they were safe to provide care and support. New staff received induction when they started and on-going training and supervision throughout their employment. Training was both face to face and on line. Internal clinical staff delivered bespoke training to support staff around monitoring people’s physical health, and ways to improve this.

Management teams both on and off site demonstrated the tools and processes in place to ensure staffing levels were more than adequate to meet people’s needs and were regularly reviewed. There were robust procedures in place to help ensure new staff were suitable for their job roles at the service. Experienced recruitment staff coordinated an ongoing staff recruitment campaign to maintain appropriate staffing levels across each of the supported living services. The provider undertook checks of potential staff prior to their recruitment to ensure they were safe to provide care and support. New staff received induction when they started and on-going training and supervision throughout their employment. Training was both face to face and on line. Internal clinical staff delivered bespoke training to support staff around monitoring people’s physical health, and ways to improve this.

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 were involved in decisions relating to their care and support, including the administration of medicines. They had choices and could self-administer, if it was assessed as safe to do so. People needed different levels of help with medication, for example help with ordering, or verbal prompts when to take it. For some people staff took full responsibility for the ordering, storing and administration of medication.

Staff received regular training on medicines management and told us they felt confident with all aspects of this. Medication competencies were checked at regular intervals by team leaders and service managers. Staff followed company protocols to ensure all medicines were prescribed safely. On occasions, people refused medications. Staff described actions they would take in these situations to try and encourage people to take prescribed medications. The service was keen to reduce the use of PRN medication where possible and staff encouraged people to keep busy with activities, such as exercise and walks.

During one of our visits, we carried out a random sample check on medication. We identified a gap in the administration of a morning medication. After counting and checking stocks it became clear the medication had been administered and this was a recording error. The provider took steps to ensure staff were reminded to keep timely and consistent records when administering medication.

Medication risk assessments were completed as part of the assessment and admission process. These outlined aspects such as the level of medication support people required from staff and where medication would be safely stored. At the time of this assessment the service was changing the levels of support. All related policies and procedures had been amended to reflect this change. Processes were in place to ensure staff were well-trained in the administration of medication and were fully confident with electronic systems (E Mar) in place. Training was both on-line and face to face with competency checks in place at regular intervals.