Minstead House

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

Systems to assess, monitor and mitigate risks to people, including risks associated with the environment, support planning and medicines management were not robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Staff did not report incidents in a consistent or timely manner, which meant opportunities to learn from these and reduce risks to people were lost. Where incidents and safeguarding concerns had been reported, lessons had not always been learned or improvements embedded into practice. The safe storage and administration of medicines was not robust. Staff failed to ensure controlled medicines were counted and recorded prior to and after administration to ensure such medicines were not mis-used. People were not adequately protected from the risk of infections. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff had not always received appropriate training relevant to their role. People's rights under the Mental Capacity Act 2005 were supported and understood by staff. Recruitment procedures were robust, and people were supported by adequate numbers of staff.

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.

Relatives told us they knew how to speak up if they had a concern about their loved one’s safety. Some relatives told us they felt these issues were not always addressed by the registered manager when brought to their attention. One relative told us how they had raised concerns in relation to furniture which had not been secured to the wall following maintenance work in the room, several weeks earlier. We found, this still had not been completed during our visit. This was brought to the providers attention who addressed it the same day.

Staff told us they had received training to help them manage risks associated with people they support. However, we found that some staff who had been employed for a long time had not completed mandatory or refresher training. Some staff told us they did not feel confident when supporting 1 person who could have unpredictable responses to situations. We observed some staff stepped back and waited for the management team to intervene and provide support at such times. Most staff told us they could make suggestions in relation to peoples support needs and any changes to improve care. One staff member said, “Sometimes I work in other services and the good things I see that we could put in place here to improve care and teamwork, I share with [Name] registered manager.” The registered manager understood their duty of candour responsibilities.

A lack of consistent training and guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. Staff did not consistently report incidents of abuse, which meant opportunities for learning and improvements to people’s care were sometimes missed or delayed. Furthermore, lessons learned were not always shared with staff and embedded into practice to help mitigate future risks.

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.

Relatives told us they understood how to raise any abuse concerns they may have. Relatives we spoke with told us they felt their loved ones were safe being supported by staff and did not have concerns about their safety until recent allegations of abuse had been brought to their attention. The provider had acted based upon the allegations of abuse which had been raised and was currently working with the service users, relatives, staff, and the local authority to ensure people were safe from abuse. One relative who was asked if they had ever had concerns about their loved one’s safety, told us, “I have never had any concerns. The staff are all lovely, they greet and hug you. [Name] is happy here and is always happy to come back when we have been out.” Two other relatives told us how their loved ones had been subject to financial abuse at the service previously but felt the process had been improved to reduce the risk of this. However, one relative told us they found it very difficult to get records of the financial transactions from the registered manager and had been waiting 3 months following their request. This was brought to the providers attention who said they would address this matter immediately.

Staff told us they had received safeguarding training and could describe circumstances which would lead to them following the services safeguarding policy and procedure. However, staff told us they had not raised safeguarding concerns with the registered manager when they had witnessed these as they were concerns about the repercussions. Evidence suggested the system for reporting incidents and accidents, which could be of a safeguarding nature, was not always followed by staff, this included the completion of body maps and incident forms. Managers did investigate and share safeguarding concerns with the local authority’s safeguarding team when they were identified. People's rights under the Mental Capacity Act 2005 were upheld. The staff and management we spoke with had a clear understanding of people's mental capacity. We saw that all people using the service had varying abilities when making decisions, which staff were clear about. For example, 1 staff member told us, “They [people using the service] need to be protected from harm but they are all different and need to be supported in different ways. They need to be listened to and we need to be inclusive when supporting them, including what we are doing so they feel protected.”

We saw that staff were aware of the safe processes associated to supporting people with complex needs, safely. For example, we saw staff supporting a person who was expressing emotional distress, in such a way to reduce the risk of harm to themselves and others. However, some staff observed took a step back rather than taking the lead. Some staff we spoke with told us they did not feel they had the skills to safely de-escalate incidents. Two fire door guards were observed to not be working on two separate days. The batteries had run out, so did not stay open. Staff had used magazines/card to wedge these doors open. Door guard checks and fire drills had not been completed consistently completed. This placed people at risk should there be a fire. We also observe one person's room, where the door was open, their window restrictor had been broken and the window was wide open. This was a known risk, as identified on the fire risk assessment for the building but additional checks had not been implemented to ensure swift action was taken. We asked the registered manager, if this had been implemented when we returned a week later, and it hadn't.

Systems and processes to protect people from abuse and neglect were not effective enough. Staff did not consistently report incidents and accidents, which increased the risk of immediate action not being taken in response to safeguarding concerns. For example, the provider had a whistleblowing hotline so that staff could report concerns anonymously, however, we found this had not been used to protect people from alleged abuse. One staff member told us how they had raised concerns about a colleague acting in an alleged abusive way to the senior on duty and they had not kept this confidential. This led to the staff member being ‘bullied’ and did not speak up about the abuse and culture in the service because of this. The provider told us they had been made aware of this during recent investigations into the allegations raised and were addressing these. People’s rights under the Mental Capacity Act 2005 were fully supported and understood by staff. There was evidence of best interests’ decision-making for people who were subject to restrictions. Where mental capacity assessments and best interest decisions had been completed, they demonstrate how conclusions had been drawn.

Relatives gave mixed views about how risks were assessed and managed. One relative told us they were concerned that another person who used the service had caused harm to their loved one over recent week, and this seemed to be increasing. The provider told us they were aware of these concerns and were working with other health professionals to help manage this risk. However, we saw that risk assessments were not always robust for specific incidents. This meant the person remained at increased risk of harm. Relatives told us that although they were contacted following incidents occurring or new risks emerging, they were not routinely involved in reviews of their loved ones needs. They told us they received the updated support plans to read and make any comments via e-mail. There was no face to face meetings to involve the people, relatives and key support staff. This was also confirmed by the registered manager.

Staff we spoke with were aware of risks to people and their role in monitoring and managing these. Staff did not always feel confident in managing people’s responses to situations and their expressions of concern. Some staff told us they could benefit from more training to help build their confidence. We saw there were some gaps in training, but the provider told us they were addressing these and providing additional support to staff to mentor and improve their understanding. Staff told us how the supported people in a way to encourage independence whilst monitoring the associated risks. The registered manager told us how they updated support plans, risk assessments, and where necessary contacted other health professionals to gain further guidance on how to manage risks for people using the service.

We observed staff actively encouraging people to make their own food and drinks in a safe and supportive way. People were supported to access the community and we saw that safe staffing levels were in place to minimise risks to people when outside of the service and using public transport.

Risks to people had not always been assessed with them or clear plans developed, with accompanying guidance for staff, for managing these. This included the failure to consistently assess and manage risks associated with people’s specific responses to situations. Some people's care plans lacked clear guidance for staff about their role in monitoring and providing a consistent approach. For example, some people's care plans did not mention responses to certain actions or needs people may have which had the potential to lead to frustration, escalating the associated risks. The management team did not have effective oversight of current risks to people due to ineffective incident reporting processes. The provider told us they had just implemented additional checks for the registered manager to complete on a daily and weekly basis. This was to ensure they were aware of all incidents which had occurred and that the relevant records had been completed, including updating risk assessments and body maps.

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

Relatives told us their loved ones were mainly supported by the same group of familiar staff, until recent weeks, when agency staffing has been increased. They felt the provider employed sufficient staff who generally knew their loved ones needs and wishes well. Relatives said they felt staff were suitably experienced for the role, but one relative said, “We are picking up the vibe that there are clicks in staff which is worrying. Staff are working against each other, and we can feel that there is an atmosphere and friendship groups. When we visit staff have always been polite but feel there is an undercurrent.” This was shared with the registered manager who told us they were aware of these and this was something which was currently being investigated.

Staff felt the provider employed enough staff to support people safely and spoke about how numbers have been increased or decreased depending on the persons level of support required. Staff we spoke with told us they had received appropriate training relevant to their role. Some staff said they could benefit from additional training, particularly in supporting people with emotional responses. This was shared with the provider who told us they had recently increased the support for staff and were continuing to work with the registered manager to provide mentoring and guidance to these staff.

We observed that staffing ratios, as per peoples assessed needs were being met. Staff were available to support people when they needed support or guidance. Staff knew people well. This was demonstrated by the positive interactions and responding to their requests. However, we saw that when some people expressed emotional distress, some staff took a step back and waited for the management team to provide support.

The provider had not always ensured staff were kept up to date with good practice and had completed all the training they needed. The provider’s staff training matrix indicated staff received regular training in many areas, but there were gaps which needed to be addressed. The provider assured us they were addressing these shortfalls immediately. Records showed not all staff received regular supervision. We saw for some staff they had not received any supervisions or observed practice for the first four months of this year. The provider gave assurances that this would be addressed in the immediate future and monitored. Staff went through an induction which included training and opportunities to shadow experienced staff to help them learn the skills they needed to understand peoples support needs. The provider followed robust recruitment procedures to ensure staff were suitable to support people in their own homes.

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.

Most relatives told us they were happy with their loved ones support they received to take their medicines safely. One relative told us they were not always assured that staff followed the care plan and applied creams as prescribed.

Most of the staff we spoke with told us they received training to support people to take their medicines safely and felt the training they received was adequate to safely administer medicines. However, senior staff were not able to tell us the correct procedures to follow when a medication error occurred. One staff member told us how they were currently completing their medicines training and they will be observed before they will be allowed to give medicines to people. The registered manager told us they were in the process of training more staff so that there was a more person centred approach.

People were not always supported to receive their medicines safely. The provider had policies and procedures for safely managing medicines, however we found staff failed to always follow these. For example, controlled medicines were not counted before or after administration or at each shift handover. The senior support worker and registered manager were not aware of this requirement although it is detailed in the providers policy and procedure. Medicines audits were completed each month; however, these had failed to identify the issues we found. The registered manager told us that they were aware that they were behind with the 6 monthly observations of staff, as per the providers policy, to ensure they adhered to safe administration processes, and this was being addressed. People’s care plans contained information about how they wanted to be supported to take their medicines. All medicines we checked had the correct balances. Creams were dated when opened, however, we saw there were 2 or more of the same creams opened and being used at the same time. Creams were stored in the same cabinets as the internal medicines. This is not in line with the provider policy and procedures. Team leaders did not follow the correct process when identifying a medicine administration error - missed medicine nor when administering controlled medicines. People receiving medicines were given encouragement and explained what was happening during the administration of medicines.