This targeted inspection of Voyage (DCA) Somerset & Devon focused solely on safeguarding systems following a concern, finding effective processes in place with no evidence of harm to people. The overall and safe ratings remain 'Inspected but not rated' as the full key question was not assessed, with the previous comprehensive rating of Good still standing.
Concerns (2)
moderateGovernance: “At the time of our inspection there was not a registered manager in post. There was a manager in post who had applied to become the registered manager.”
minorCare planning: “One of the guidelines we reviewed had not been updated to reflect the current support for the person, the manager updated this during the inspection.”
Strengths
· Effective safeguarding systems and processes were in place and being followed.
· Staff understood how to identify and report abuse internally and externally, including to the local authority.
· Relatives confirmed people felt safe, with one stating 'Absolutely I think [Name of person] is safe.'
· The service worked well with other agencies to safeguard people from abuse.
This focused inspection of Voyage (DCA) Somerset & Devon found the service remained Good in Safe and Well-led, despite historical issues with unstable management, high staff turnover and reliance on agency staff. A newly appointed manager was actively addressing concerns through a recruitment drive, reassessments and improved governance, with early improvements already evident.
Concerns (10)
moderateStaffing levels: “The service had not always deployed enough appropriately skilled staff to meet people's needs and keep them safe. This had led to inconsistencies in people's care and support.”
moderateStaffing levels: “agency staff had been used who did not know people's needs and were restricted in how they could support people. Other times they had been running with not enough staff due to sickness.”
moderateLeadership: “there had been a time when this was not always the case due to poor management of the service.”
moderateGovernance: “unstable management in the past not always liaising with the housing providers.”
moderateStaff competency: “people had not always been supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have.”
moderateSafeguarding: “Some staff members felt they had raised concerns which had not always been acted upon in the past.”
minorStaff training: “the recently appointed manager had identified that further work was required on training staff to communicate using a wider range of methods.”
minorIncident learning: “there were times it was reported this was not always the case due to inconsistent management leading to communication issues.”
minorCommunication with families: “Some relatives had not spoken with management in the past”
minorInfection control: “Relatives had some mixed views about staff use of personal protective equipment (PPE) such as wearing of masks.”
Strengths
· Staff understood and implemented STOMP principles to avoid over-medication
· Staff knew people well, promoted privacy, dignity and culturally appropriate care
· New manager visible, approachable and had a clear action plan within a month of post
· Effective infection prevention and control measures with PPE used in line with guidance
· Person-centred one-page profiles available to support new and temporary staff
Quality-Statement breakdown (12)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Promoting a positive, person-centred, open, inclusive and empowering cultureNot rated
well-led: Duty of candour and openness when things go wrongNot rated