Cascade (Hurst 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service. This key question has been rated outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 91 (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 had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Staff told us they felt comfortable in raising concerns in the knowledge that they would be respected and listened too.

Incident reduction year on year involving people that used the service and, or incidents directed at staff represented a shift in culture and showed the effectiveness of staff training, familiarity and reflection, staff were able to move from reactive crisis management to using proactive behavioural strategies. This meant staff had become skilled in identifying people's needs and understanding what might distress people and what strategies they could use to distract the person or re-engage them. Emphasis was placed on giving not only the staff the skills to divert unwanted behaviours but also the people the skills to self-regulate.

The management team reviewed incident forms to consider if actions taken were appropriate and if staff had followed the correct procedures, care-plans, and risk assessments. There was a section looking at who staff had informed of the incident, any follow up actions required including lessons learnt and debriefing for staff which staff confirmed happened regularly.

There was a continuous emphasis of reviewing, analysing, and sharing good practice across the home and other provider services to ensure safety was embedded and had a no blame culture to help ensure staff were willing to come forward and take responsibility.

By continuously reviewing incident data the management team were able to understand why behaviours were occurring and what positive changes they could make to ensure the least restrictive approach was used by staff to reduce incidents. Examples included: Changing staff, amending the environment or activity or identifying and reducing known triggers. Changes to people's routines were planned wherever possible and people were supported by visual information and, or social stories to help them understand or manage a change or unfamiliar situation like a staff change or doctor's appointment.

A staff member said, “After an incident staff are debriefed a deputy comes to the floor and will review and learn from incidents and minimise distress by reducing occurrences. They carry out checks regarding health and how this might affect their behaviour and monitor moods or changes in routines. We check vital signs to see if there are any variations, check records and if necessary, call 111 to seek advice.”

Staff completed an accredited training course, ‘team teach’ so they could hold people safely to prevent injury to themselves or the person experiencing stress. Staff were able to administer prescribed antipsychotic medicines to help support people who were experiencing distress. But this was kept to a minimum with tight controls, guidance and regular review of the use of this medication to ensure it was the most appropriate option when other least restrictive options had not achieved the desired outcome.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored.

People received holistic, integrated support which meant people received good outcomes of care.

There was partnership working with family members and the service placed a high emphasis on promoting health and well-being to reduce the negative impact of unhealthy lifestyles, through education and support. We spoke with several health care professionals including the nurse who visited the service weekly who expressed their satisfaction with the staff’s knowledge of people they were supporting and how quickly they responded to changes in people’s needs. Staff were trained to look out for changes in people’s health as an early indication of pain and, or infection. People’s care plans included details of their health and communication needs and if someone was feeling unwell staff would complete vital checks such as temperature and blood pressure to see if these were elevated and required escalation to a medical professional. Vital checks had been introduced because of some peoples limited ability to communicate and express pain.

A health tracker for each person demonstrated that people had an annual health check, regular medication reviews and saw a range of professionals in line with their needs.

Care plans were up to date to ensure information was accurate and information was shared on a need-to-know basis with the person’s consent and in line with the Data Protection Act 2018. If a person required secondary care they were supported by staff familiar with their needs throughout their treatment to ensure a consistent approach.

Staff used social stories which gave a simple narrative to help people understand unfamiliar situations, communication aids to help people understand their choices and staff ensured people were involved as much as they could.

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives whilst 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 had built up trusting, caring relationships with people they were supporting, and they enjoyed each other’s company with staff being able to recognise changes in people’s behaviours.

Staff we spoke with were able to give a good account of their understanding of safeguarding and what would constitute abuse and actions they would take if they suspected abuse. All staff expressed confidence with their manager and wider management should they need to raise concerns. All staff were familiar with external agencies and when to report should they feel it necessary.

Staff’s safeguarding knowledge was strong, and their knowledge and understanding were discussed in one-to-one staff supervisions, team meetings, debriefings and through training and competency assessments to evaluate staffs’ knowledge. Managers were safeguarding leads with enhanced knowledge.

People were supported to explore their emotions, feelings and boundaries. Staff gave people space to work on their feelings and identity things that made them sad. A historical allegation of abuse was thoroughly investigated with the person front and centre of the investigation in which they were able to identify the alleged perpetrator. Information was made accessible to people to help them understand what abuse was and what actions would be taken.

We spoke with the family member about this incident, and they told us that robust steps had been put in place following the incident and they were assured of the continued safety of their relative and learning they took place following the incident.

Policies within the service were underpinned by good practice guidance such as ‘Reducing the need for restraint and physical intervention’ and through skilled de-escalation staff were able to reduce the need to use restrictive practice such as safety holds and medication. Staff were adequately trained to recognise potential triggers for people’s stress and how to support people to self-regulate. This was important in keeping everyone safe.

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

Risk assessments were used as enablers rather than restrictions. Staff worked with people to understand what mattered to them and adapted environments and support to make activities possible rather than limiting them. For example, people were supported to cook, exercise, and access the community safely through tailored planning and consistent staffing, enabling them to develop skills and confidence while remaining safe. This demonstrated rights-based care as a core principle.

People’s care plans, risk assessments, health care plans and positive behavioural support plans were all embedded, so staff had access to all the information in one place. A staff member told us “There are highly comprehensive support plans, risk assessment and PBS in place. These are regularly updated as needs arise. There are what guide and support staff to appropriately support the residents.”

Staff spoken with had a very good understanding of people’s needs and associated risks and where a DOLS or best interest decision was in place staff were aware of this. A staff member told us mealtimes were always supervised as one person required a specialist diet and others had epilepsy and or could eat too quickly increasing the risk of choking.

Risk reduction was partly achieved by the sensitive layout of the building which was intuitive to people’s needs and staff were proactive in identifying risk and eliminating them. An example of risk reduction was observed during the inspection. Staff supported people in line with their needs and consideration was given to the space people required. People were supported to develop independent living skills and whilst we observed people in the main kitchen there was also a training kitchen where people could receive one to one support. The kitchen was minimalistic and reduced the level of distraction to enable staff to focus on the support the person needed,

Positive risk taking was considered in line with people’s needs and interests and in line with best interest decisions. Some people without support were prone to ‘overeat’ or eat foods which had high calorie intake and contained a lot of sugars and fat. Staff worked with people to encourage and promote healthy living through a combination of healthy foods, and a programme of exercise. People regularly went swimming, out for walks and exercised in the gym. This was all carefully risk assessed to ensure the benefits were measurable and outcomes were achievable.

Whilst people could make informed choices about what they ate, unhealthy snacks whilst available were discouraged in favour of healthier alternatives. Diets were considered in line with people’s health care needs, preferences and in line with guidance from other professionals such as speech and language, the learning disability team and dietitians.

Fire marshals were clearly identified and staff confirmed there were weekly fire tests and clear evacuation processes in line with people’s individual needs, personal emergency evacuation plans, (PEEPS.) Staff spoke of a roll call to ensure everyone was accounted for and records showed drills were conducted three monthly both day and night.

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

There was a designated health and safety lead and maintenance team who could be reached at any time and undertook a series of well-planned health and safety checks and completed environmental risk assessments.

Environmentally the property was well maintained, clutter free and there was good oversight of health and safety. Risks from the environment were pre-empted and the house sensitively adapted to help reduce risk. For example, there was underfloor heating, intuitive lighting, rounded edges to reduce the risk of injury, lots of space and a garden which created different areas of interest but was secure. Clear environmental risk assessments were in place and there were detailed emergency procedures which staff were familiar with.

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.

Care staff told us they were supported with opportunities for advance studies robust induction and training, which was role specific.

High staffing levels had been achieved through a clear assessment of people’s needs and risks and regular reviews of people’s needs. A two-stage interview process was designed to assess staffs’ reaction and interaction with people using the service and ensure people were engaged with recruitment and had influence over who supported them. Family member told us, “It is difficult bringing new staff into their routine, but they are always supported by a staff member who knows them well, with new staff shadowing more experienced staff.”

The organisational structure enabled staff to gain internal promotion in line with additional responsibilities. Champion roles helped recognise staff skills and attributes and gave them a lead responsibility for a key area of practice.

Most people had high staff ratios which enabled people to have one to one activity and be supported safely in the community.

Nighttime staffing was significantly reduced but there was an extra staff member who slept on the premises and could be called upon when necessary. Night staff we spoke with were knowledgeable and experienced. They told us they felt part of the team and were supported through a robust on call system. They told us they felt safe and said at nighttime the situation was calm. The provider told us they monitored incidents and should there be a spike at night they would increase night staff as required.

The home was fully staffed, and agency staff had not been used for a while which increased the resilience of the service. Recruitment and induction processes were robust and exit interviews helped the organisation understand why staff left and how this information could be used to improve staff’s experience.

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.

The home was clean with clear responsibilities for cleaning and cleaning audits to ensure standards were maintained. A regular visiting healthcare professional told us, “The home is spotless that’s the norm.” A family member said, “it's always lovely when you go there, very clean environment.”

People were supported to take care and pride in their environment and were supported by staff to do so. Night staff told us they completed cleaning schedules at night but within reasonable hours. We spoke with family members and visitors who confirmed the house always remained clean and orderly.

Infection control training was provided for staff to help ensure they knew the correct procedures to follow to reduce and minimise the risk of infection and how to use appropriate personal protective equipment as required and complete effective hand-washing. Infection control policies underpinned good practice.

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

An electronic system of medicines records was in place and used effectively by staff. Incidents relating to medicines had reduced since the introduction of the electronic system and there were tight controls to ensure people were administered their medicines safely and at the correct times. Staff administered medicines in a quiet area away from any unnecessary noise. Medicines were always administered and checked by two members of staff to reduce the likelihood of an error occurring. We observed medicines being administered and staff were very calm, explaining what they were administering and taking great care to ensure the person swallowed their medicines. Staff received training and assessments of competence over an extended period to ensure they were comfortable and had the necessary skills. Over 90 percent of staff demonstrated skills and confidence in medicine administration practices. Medication reviews helped to ensure people were only prescribed what they needed, and any changes were clearly authorised.

The staff were aware of (STOMP) Stopping Over-Medication of People with a learning disability, autism, or both and told us that the reduction of antipsychotic medicines were always discussed and reviewed at GP and psychiatry appointments. Some people took no medication at all, and some people had medicines introduced for a short while to stabilise their mood, but this was closely monitored, and where possible reduced or stopped all together.

The use of PRN medicines ‘prescribed as necessary’ were carefully scrutinised to ensure the use of chemical restraint was carefully balanced with clear strategies. De-escalation was often effective reducing the need for PRN medicines because staff knew what situations and, or events might cause people more anxiety and required careful planning such as anniversary’s, the festive season, or unfamiliar and noisy environments. Prior to any such occasion or activity staff carefully monitored people’s mood and presentation to help ensure there was no escalation.

People’s care plans documented if they might find it difficult to express pain. As part of a trial and innovative practice an electronic pain checker had been introduced which used facial software to help support staffs’ decision-making processes in assessing if someone was in pain and would benefit from painkillers as and when necessary. This helped ensure the effective use of pain relief.

When a medicine error occurred, there was a review of circumstances. The main contributing factor was staff dropping medicines, as a result a table was purchased for staff to use when dispensing medicines. Medication errors had occurred when people were on social leave so the staff created information packs to explain to families the different medicines and when they should be administered to reduce the risk of further error. This showed how the staff used incidents to inform better practice. The pharmacist told us, “Carers are thorough and fully aware of each resident’s medication and treatment regimen. For example, when medication changes were made in secondary care but not communicated to the GP surgery, the GP initially issued a prescription based on the previous treatment regimen. The carer promptly identified the discrepancy and liaised with us and the GP surgery to ensure the most up-to-date treatment regimen was prescribed.”