Pharos Supported Services

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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

Systems to assess, monitor and mitigate risks to people, were not always robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Where incidents and safeguarding concerns had been reported to the provider, lessons had not always been learned or improvements embedded into practice. People were not always protected from the risk of infection. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Recruitment procedures were robust, and people were supported by adequate numbers of staff.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives provided mixed feedback about the care people received. Some people and relatives were very happy, and some told us improvements needed to be made. One relative told us, “The care is not good.” Another relative told us, “I am very pleased, they [staff] know them[person] well, with a few bumps along the way.” A third relative told us, “Yes they [person] are safe.” It was not always clear what learning took place following an incident. A complaints policy and procedure was in place, however some relatives were not satisfied with how their concerns had been dealt with, we shared this information with the provider who agreed to follow up on this.

Staff told us there had been a high staff turnover at both care staff and management level and things were just starting to settle and improve. The registered manager understood their duty of candour responsibilities, but these were not always acted on in practice. Following our feedback, the provider told us they had implemented a new system to record lessons learnt when reviewing safeguarding incidents, with the intention that the actions taken to mitigate risks to people and reoccurrence would be consistently recorded.

We received some positive feedback from stakeholders about how the provider had worked well with them. However, we also received mixed feedback from external stakeholders about some inconsistences in the service due to staff and management team changes, which had impacted on the quality of the service.

Staff reported incidents and accidents, however; the systems in place to ensure learning from these took place were not always consistent. Care plans and risk assessments were not always in place for known risks, kept up to date or reviewed following an incident. This meant opportunities for learning and improvements to people’s care did not always take place. The registered manager completed investigations into safety incidents or complaints brought to their attention. However, lessons learned were not always embedded into practice to help mitigate future occurrences.

Most relatives told us people received good support to access healthcare services and support. One relative told us, “They [staff] are on it.” However, some relatives told us communication with staff about their loved one’s care could be improved.

Most staff had a good understanding of people’s needs. Staff told us they had an opportunity to read people’s care plans and were provided with key information when someone new was joining the service. We discussed with the provider how they shared significant information about people, for example in relation to potential risks, with other providers when people transitioned to another service. The provider told us following our discussion that, although a process for this was in place, they had updated their admission policy, following our discussion, to ensure this process was more clearly stated.

We received some mixed feedback from stakeholders. Some told us the provider had worked well with them. However, we also received some mixed feedback regarding inconsistences in the service due to staff and management team changes, which had impacted on the quality of the service.

The provider had processes in place for the continuity of care between services. This included an initial needs assessment at the start of the service being provided. The provider told us they had a team that supported the initial referral and transition process. However, we saw for 1 person whose care records we reviewed, that although an initial assessment of risks had been completed prior to admission no care plans or risk assessments had been developed to guide staff on how to manage identified risks.

We received mixed feedback from people and relatives we spoke with about their care. Most relatives were very positive about their family member’s care. Relatives knew how to raise concerns, although some were not satisfied with how concerns were dealt with.

Staff told us they were aware of the provider’s safeguarding policy. They told us they had completed safeguarding training and had a good understanding of the actions they would take if they had any concerns about abuse. Staff told us they felt confident that concerns raised with their line manager would be acted on. Staff and management we spoke with had some understanding of people's rights under the Mental Capacity Act 2005. We saw staff encouraged people to make everyday decisions. However, there was a lack of clarity and at times confusion about what safeguards were in place for people under close supervision. For example, in supporting living settings the local authority apply to the Court of Protection for an order to deprive a person of their liberty. Some staff did not understand this process and the outcome of these applications was poorly recorded in people’s records.

Some people were living in a supported living property where the needs and preferences of the different people living there had not been adequately assessed, creating risks to 1 person. Although some measures and strategies were in place, these were not always successful, and the person remained at risk of harm.

The provider had systems and processes to protect people from abuse and neglect and safeguarding alerts were raised with the local authority. However, following some incidents, care records and risk assessments were not always robustly reviewed to ensure the measures in place remained appropriate, and people were protected from harm. Some risks considered historical, were not considered, and planned for, and again this has the potential to place a person at risk of harm if appropriate guidelines are not in place for staff to follow. People’s rights under the Mental Capacity Act 2005 were not fully supported or always understood by staff. There was a lack of clarity and oversight of when a deprivation of a person’s liberty had been approved, and any associated conditions. The provider sent us updated related information after our site visit. However, this did not indicate there was a clear understanding at both staff and management level.

People and relatives gave us mixed views about how risks were assessed and managed. Some relatives told us they had regular opportunities to discuss their family member’s care, but some told us such opportunities were infrequent. One relative said, “On the managerial side, it’s not as it should be, but we have so much day-to-day contact [with staff], so it is not an issue.” Another relative said they participated in a care review every 12 months. A third relative told us, “I’m not asked my views about their [person’s] care.”

We received mixed feedback from staff on the assessment and management of risks to people. Some staff knew the people they supported well and knew how to support them to stay safe. However, some staff also told us it was difficult when working alongside agency staff because they needed to take the lead when supporting people due to agency staff’s limited awareness of risks.

We saw some risks to people in the environment.

Risks to people had not always been assessed with them or clear plans developed, with accompanying guidance for staff to follow. Some people’s care plans had missing or contradictory information, including guidance on risks in relation to health conditions, and eating and drinking. This placed people at increased risk of harm. Reviews of risk assessments did not always consider if the measures in place to manage the risk remained appropriate. When we raised this with the provider they took immediate action.

People told us they liked their home and had been supported to personalise their own living space. However, we saw some of the supported living houses had not always been well maintained and this placed people at increased risk of harm.

The provider told us about one supported living house that was no longer suitable, and they were working with the people and their representatives so alternative living arrangements could be found, and this work was well under way.

In some of the supported living properties we visited we saw items of furniture requiring repair and damaged flooring.

The provider had systems in place for assessing environmental risks in each supported living property. However, processes were not clear when items belonging to an individual were damaged or posed a potential risk. Regular audits and checks were completed on the supported living environments, but these were not always effective or timely. For example, we saw some items of furniture requiring repair and damaged flooring.

People told us the staff were kind and friendly. One person told us, “The staff are brilliant.” Another person told us, “I get on with the staff and they are kind.” However, we received mixed feedback on staff from people’s relatives. Some relatives spoke very highly about the staff team whilst others had a poorer experience. Some relatives told us there had been a lot of staff changes at the service and this had caused uncertainty. A relative told us, “Some (staff) are good, some don’t look like they want to be there.” They went on to say, “Some [staff] don’t seem right for the job.” Another relative told us, “I know each one [staff member] very well. I know their strengths and weaknesses. They are a lovely team, really lovely.”

Staff told us there had been a significant number of staff changes and this had impacted on people’s care and support. They told us agency staff were used to support the rota but this often put extra pressure on permanent staff because they would need to take a lead in supporting people. However, staff told us the staffing arrangements were starting to improve. Staff told us they received the training they needed to carry out their role. They told us staff supervision meetings to discuss their work practice were infrequent. The provider told us where they needed to use agency, they used the same company and staff that were familiar with people living at the service. People were consistently receiving their commissioned staffing levels.

Some people had commissioned 1-2 and 2-1 support and we saw these staffing levels were maintained.

We requested information from the provider about staffing, and this confirmed a high turnover of staff, although improvements were starting to take place. There had been a number of changes at care staff level and within the management team. We met a number of staff who were recently promoted or new into post. Records of staff supervision dates confirmed this had been infrequent. However, the provider told us improvements were being made on the frequency of this support. The provider’s training matrix indicated staff received training in a number of areas and staff confirmed this. Some training updates were due and plans were in place for this training to take place. New staff went through an induction which included training and opportunities to shadow experienced staff to help them learn the skills they needed. The provider followed robust recruitment procedures to ensure staff were suitable to support people.

People and their relatives told us staff wore personal protective equipment (PPE) when needed.

Staff told us they received training in infection prevention control. Staff told us they had access to plentiful supplies of the right PPE. The provider and staff were aware of current relevant national guidance.

In one supported living house, we saw some staff members’ coats and bags were hanging on the sofas in the communal lounge where people were sitting. In another supported living house, we saw some flooring was damaged with parts of the lino missing and torn and worn, which made it difficult to maintain good hygiene standards. We saw a buildup of dirt and debris in some people’s rooms, and this increased the risk of infection.

Regular audits and checks on standards of cleanliness were completed in each of the supported living houses. However, the follow up actions identified were not always addressed in a timely manner, and cleaning schedules were not always completed or available for us to see. Staff had access to policies and procedures on infection prevention and control to ensure they kept up to date with any changes in guidance. Infection prevention was included in staff inductions and refresher training was provided periodically to ensure staff remained updated with current guidance and practices.

People told us they were happy with the support received to take their medicines safely.

Staff told us they received training to support people to take their medicines safely. A staff member told us, “I have completed the required training and I feel confident to administer medicines safely.” Some staff were required to carry out specific medicine tasks that required additional specialist training and competency, we saw this training had taken place.

We saw in one of the supported living properties that we visited there were missing staff signatures on medicine administration records (MAR). In another property there was no protocol in place to guide staff, for a person taking medicines on an ‘as required basis (PRN). In addition, for a person who refused their prescribed medicines there was no written guidance from healthcare professionals to guide staff on what steps they should take, to ensure the wellbeing of the person.

The provider had policies and procedures for managing medicines, although these were not consistently followed. During the site visits it was difficult to ascertain which staff had successfully completed their medicine competencies, so they were safe to support people with their medicines. Following our site visit the provider did provide reassurance and information to us regarding this. Where medicines errors had occurred, investigations were completed to identify the cause.