Godfrey Barnes Care SL East Midlands

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 systems and processes embedded at all levels of the organisation to ensure that incidents could be used as learning events. There was evidence of a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Incidents and accidents were recorded individually by the staff who witnessed them, and the provider had systems in place to ensure accidents and incidents were regularly analysed for to identify any emerging themes or patterns to improve the care provided. When incidents occurred, staff and people were supported to reflect on any learning from the event to reduce the risk of recurrence.

The provider used a previous unsuccessful admission as a learning event - we found the provider recognised the issues that had led to that placement breakdown, and made alterations to their admissions process to ensure that similar issues did not reoccur.

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. We found staff had been proactive in seeking support when they identified concerns about a person’s health. Staff had provided external professionals with the necessary information and observations. This led to the person receiving the support they required in a timely way, which ensured the person’s ongoing emotional and physical wellbeing. There was open communication with external stakeholders including medical services, support organisations, community groups and relatives The provider used a variety of methods of communication, with regular MDT meetings for people, their families and care teams in which all aspects of people’s care and treatment were discussed. Regular updates were sent to family members via email, and any important urgent information - for example health updates – were communicated by telephone calls with family. A monthly newsletter was used to inform stakeholders of wider provider news.

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 with other professionals as required.

Staff demonstrated a knowledge of how to raise safeguarding concerns, and leaders took a proactive approach in investigating safeguarding concerns internally to ensure quality improvement within the service. The provider had systems in place to investigate safeguarding incidents. We reviewed recent safeguarding events and found that appropriate actions had been made to reduce the risk of reoccurrence. We saw evidence of learning from these events, for example the provider had made changes to their own systems to improve their processes. The provider then introduced a policy that any referral to services needed to be evidenced with a documented paper trail. People we spoke with told us that they felt safe in their living environment and with the staff who support them. One person stated “It feels safer here than anywhere else that I’ve been”.

The provider worked with people to understand and manage risks by thinking holistically, involving people, their family members and care teams in decision-making and planning. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider had positively managed a person’s known risks by working with them to ensure their needs and wishes were met.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Each person’s living space was adapted to meet their needs, and properties were designed to ensure that each person had their own private space. Some properties had communal spaces, there was sufficient space to ensure people could have their own personal space and dignity without having to access communal spaces if they did not wish to do so. CQC do not regulate the premises as these are the responsibility of the landlord, however, we saw evidence of the systems in place to ensure the premises were kept safe. Any maintenance issues were reported and dealt with proactively, and regular audits were carried out by staff to ensure the safety of the environments.

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. We received mixed feedback from staff about how they were supported by the provider and management team. The majority of staff told us they felt supported and felt safe at work, other staff told us they did not feel sufficiently supported. We raised this with the provider, who told us of the actions they would take. We found evidence of processes such as, ‘weekly walkarounds’ and monthly audits that ensured managers visited all properties in order to provide oversight – leaders informed us they used these onsite visits as an opportunity to support staff.

When we previously inspected this provider in 2022, we identified breaches in relation to fit and proper persons employed, we made a recommendation about the provider’s oversight of recruitment systems. During this inspection we saw the required improvement as systems and processes were now in place to ensure the provider’s oversight of recruitment. This included the provider now having a dedicated recruitment department in place which ensured safe recruitment practices were followed.

The provider had ensured there was adequate staffing for each property, and this was confirmed by our observations when visiting the properties. All of the staff members we spoke with were positive about the training they had received both during induction and ongoing throughout their work with the provider.

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. Daily, weekly and monthly audits were in place with oversight from leadership in order to ensure that the risk of infection was minimised. The auditing processes were compliant with the Infection Prevention and Control (IPC) code of practice. We observed staff wearing protective personal equipment (PPE) at times when they were required to do so, for example, when preparing meals.

Medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medication was stored safely in locked cabinets, and people who were able to were involved in the administration of their medication.

Medicines were administered by trained staff who received regular checks and direct observation of their practice. Stock levels corresponded with the records in place and audits of medicine administration records were conducted regularly by the management team and provider. Audits had identified when recording issues had occurred and the manager had taken appropriate action to address this with staff.

The provider communicated with GPs, psychiatrists and other medical professionals to ensure that prescribed medication was appropriate and safe for each person.