This focused inspection of Potensial North East Supported Living found the service had made sufficient improvements since its previous 'Requires Improvement' rating, with Safe and Well-Led both now rated Good and breaches of Regulation 17 resolved. The overall rating improved to Good, with only a minor observation about recruitment application form templates requiring enhancement.
Concerns (1)
minorRecord keeping: “some of the templates such as application forms would benefit from enhancement. For instance, making it clear on the application form prospective employees needed to provide a full employment history.”
Strengths
· People were regularly asked for their opinions and involved in discussions about their support in ways they understood.
· Staff understood people's needs and how to manage presenting risks; risk assessments and care plans were detailed and in place.
· Clear protocols were in place for emergencies involving behaviours which challenge.
· Medicines were safely received, stored, administered and destroyed; STOMP principles were implemented.
· The service responded appropriately to accidents and incidents, analysing records for patterns and using incidents as learning opportunities.
Potensial North East Supported Living was rated Requires Improvement overall at its first inspection, with breaches of Regulation 17 (Good Governance) due to ineffective quality assurance, incomplete medicine error records, and inadequate risk protocols for behaviours which challenge. Strengths included a person-centred culture, good staff supervision, effective multi-agency working, and positive experiences reported by people and relatives.
Concerns (6)
criticalCare planning: “Care plans did not always provide enough detail around behaviours which challenge. Clear protocols were not in place for staff to follow in the event of an emergency.”
criticalGovernance: “Quality assurance measures were not always effective. Although regular audits were taking place, they did not identify the issues we found on this inspection.”
moderateStaff training: “Not all staff had completed training in behaviours which challenge and training to support people with learning disabilities.”
moderateStaffing levels: “People who displayed behaviours which challenge were supported by one member of staff only. We were not always assured the risks of lone working had been fully assessed.”
moderateIncident learning: “Medicine error records were incomplete and therefore we could not be assured these incidents had been analysed and lessons had been learnt.”
moderateMedication management: “Medicine errors had been identified, however, important information was often missing. It was not always recorded what action had been taken or how this error could be prevented.”
Strengths
· People felt safe and staff understood their safeguarding responsibilities with mandatory training completed.
· Pre-admission assessments were detailed and introductory visits arranged to ensure compatibility between service users.
· Staff had regular supervisions and appraisals and felt supported by management.
· Person-centred care plans recorded individual needs, preferences, history, goals and what a good day looked like.
· Easy read documentation used throughout to support people's understanding and decision-making.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safely; learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced diet
Good
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needs; improving care quality in response to complaints or concernsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood