Targeted inspection found previous concerns about drug use, anti-social behaviour and reporting to commissioners/CQC had been addressed, with improved risk assessments, safeguarding reporting and governance oversight. No new ratings were awarded as only specific parts of safe and well-led key questions were reviewed.
Concerns (3)
moderateSafeguarding: “At our previous inspection we had found that the provider's safeguarding policies and procedures were not operating effectively.”
moderateIncident learning: “Concerns that arose about potential harm were not consistently reported to the authorities that needed to be informed, including CQC.”
moderate
Governance
: “At our previous inspection the quality monitoring checks had not fully addressed the anti-social behaviour and risks presented to people using the service.”
Strengths
· Risk assessments were thorough and potential risks that people faced whether by their addiction issues or by displayed behaviour were identified.
· Incidents, including those that needed to be raised as potential safeguarding concerns were being reported and the level of incidents was declining.
· The provider's quality monitoring systems were now effectively assessing, monitoring and mitigating the risks presented to people using the service and others.
· Staff followed effective infection control procedures and liaised well with local infection control healthcare professional.
· Risk assessments for black and minority ethnic clients and staff had been completed and a service wide plan and guidance had been developed to address these considerations during the pandemic.
Quality-Statement breakdown (5)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsNot rated
St Martins of Tours Housing - 158-162 New North Road improved its rating from Requires Improvement to Good following a focused inspection of the Safe and Well-led key questions. Safeguarding, governance, infection control and partnership working had all improved significantly, with only two recent medicines errors noted that had been promptly addressed.
Concerns (1)
minorMedication management: “there had been two very recent errors which were the result of staff not following the clear instructions for providing particular medicines.”
Strengths
· Improved oversight and management with transparency in sharing information with people using the service and stakeholders.
· Safeguarding incidents being consistently reported, with declining number and severity of incidents.
· Robust infection prevention and control measures, including meeting COVID-19 vaccination requirements.
· Person-centred risk assessments tailored to individual care and support needs.
· Effective quality monitoring systems including daily and weekly checks and audits.
Quality-Statement breakdown (11)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements