Derby

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service. At this inspection the rating is good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff described a supportive environment where they felt able to raise concerns, and policies such as whistleblowing encouraged openness. However, the provider did not always have structured systems in place to learn from incidents or near misses. For example, there were no formal incident or accident audits, meaning themes and learning were not routinely identified. This limited opportunities to embed service‑wide improvement. Care plans were detailed and often strong, but learning from incidents and near misses was not captured in a way that informed organisational development. We raised this with the provider, who acknowledged this, and has already begun to implement this change.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Care plans showed a clear understanding of individual risks, including falls, diabetes, mental health needs, safeguarding concerns and community safety. Risks were based on personalised behaviours rather than generic statements, with clear mitigation strategies. For example, staff used structured supervision and consistent routines to reduce risk for people with dementia. There was strong evidence of multidisciplinary working with nurses, social workers, mental health teams and advocates.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff consistently described safeguarding as protecting people from harm, abuse and neglect, and knew to report concerns immediately. Historical safeguarding concerns were addressed through strengthened processes such as secure medication management and involvement of external professionals. Staff said they felt confident to speak up, supported by accessible safeguarding and whistleblowing policies, and a culture where concerns were taken seriously.

There was no one subject to Deprivation of Liberty Safeguards (DoLS). Staff had training in this area.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff involved people meaningfully to manage risk. Care plans were person‑centred, written in accessible language and captured what mattered to people, such as routines, communication needs and emotional triggers. Staff balanced autonomy with safety, recognising that people sometimes made choices that increased risk. For example, when a person preferred to spend long periods in the community or declined elements of care, staff used encouragement, reassurance and clear contingency planning rather than restrictive practice. People with fluctuating mental or physical health were supported sensitively, with staff adapting their approach based on the person’s needs at the time.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Care plans included detailed environmental risk assessments, identifying hazards such as clutter, mobility issues, uneven flooring or risks linked to pets. Staff used appropriate equipment such as hoists, and carried out checks at each visit to ensure people remained safe. Community‑based work also considered environmental factors, with staff assessing whether locations and travel arrangements were appropriate for each person. Lone‑working procedures were clearly set out, requiring staff to carry phones, check in as arranged and leave immediately if unsafe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, despite recruitment files containing appropriate checks including DBS, right‑to‑work evidence, references and health declarations some did not clearly show a continuous three‑year employment history, meaning assurance around past employment could not be fully confirmed. People and relatives generally reported that staff were caring, respectful and well trained. However, some feedback indicated inconsistent communication about staff attendance, including occasions where staff arrived early, attended without notice, or were not the preferred staff member. We fed this back to the registered manager, who has since taken action to address this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff followed safe hygiene practices and supported people with skin integrity, continence, and personal care needs. Care plans set out clear routines for personal care support, skin checks and use of barrier creams, with staff monitoring for signs of soreness or infection. Relatives described staff as “kind and caring” and said they helped keep homes clean and safe. There were no concerns that people were exposed to infection‑control risks or that staff failed to follow appropriate hygiene practices.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Where people did not receive support with medicines, this was clearly recorded. Where support was required, staff and community nurses followed clear and appropriate procedures. Medication Administration Records [MAR] charts showed consistent recording without gaps, with correct timings and clear identification of any ‘as and when required’ (PRN) medication. Safeguarding controls were in place where people had previously been at risk of medication misuse, ensuring medicines were stored securely and administered only by trained professionals. Medicines information in care plans aligned with people’s assessed needs and supported safe practice.