Three Cups

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 newly registered service. This key question has been rated 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 a proactive and positive culture of safety, based on openness and honesty.

People and their relatives told us staff listened to their concerns and responded openly and transparently to the issues they raised. This showed people felt heard and that the service was responsive to individual concerns and feedback. One person told us, "Staff check in with me to see how I’m doing. They listen to any concerns that I have, and they also give me ideas on how I can resolve them”.

Records showed the provider had systems in place to record, review and monitor accidents and incidents. Senior staff reviewed these records to identify patterns, trends and potential causes, which supported a more informed approach to reducing risks and improving safety. Learning from accidents and incidents was shared with staff, helping to improve practice and promote an open, transparent culture focused on continuous improvement.

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.

The registered manager told us the service had implemented a robust pre-assessment process to gather essential information before people began receiving support.

Completed assessments showed the service considered whether it could safely meet each person’s needs, including any risks and support requirements. Records also showed people and, where appropriate, their relatives were involved in the assessment process.

Following this, the management team developed personalised care plans and risk assessments which reflected people’s needs, preferences and identified risks. Staff confirmed this by telling us that the management team met with them to discuss each person’s support needs, encouraged them to ask questions, and ensured they had read the relevant care plans and risk assessments. This helped staff to be informed and prepared to deliver safe, personalised care. One staff said, “I read the care plan, speak with the person and my colleagues, and observe their needs. For example, I know my [Person] likes doing crafts and I do encourage and support him in doing. The manager also meets with us to discuss [peoples] care plans and risk assessments this helps me to ensure I’m clear on how the support should be delivered."

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff supported people on improving their 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.

People and relatives told us they received safeguarding information before support started, helping them understand how to recognise and report concerns. One person told us, when I moved in, I was given information about how I can raise a concern and report issues, which I would do if I had any.”

The provider had safeguarding policies and procedures in place which guided staff on how to identify, report and escalate concerns. Records showed safeguarding concerns were recorded and referred to the local authority where required, although there had been no reported safeguarding concerns at the time of inspection.

Staff completed safeguarding training and demonstrated they understood how to recognise and respond to concerns, including escalating immediate risks to the management team or the emergency services such as the police. One staff member told us what actions they would take if they felt a person was at risk. “I would make sure they are safe, report it to my manager straight away, and follow the safeguarding policy.

Management oversight, including spot checks, audits and reviews, which helped ensure safe care was delivered in line with people’s care plans and risk assessments, and supported ongoing improvement in safeguarding practice.

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.

The provider had effective, person-centred systems to assess, review and manage risks to people’s safety and wellbeing. People, and where appropriate their relatives, were involved in identifying and reviewing risks, which supported shared decision-making and helped ensure support remained responsive to people’s needs.

Risks assessed included falls, managing people’s epilepsy, environmental hazards and accessing the community.

Staff told us they were actively involved in assessing and reviewing risks, and records showed risk management was regularly reviewed. This proactive approach helped reduce incidents and supported people to live safe, enjoyable and fulfilling lives.

One staff member told us, “As part of my role, I review people’s risk assessments and update them when required. If I identified a new risk, I would speak with my manager about the concerns. We would then complete a new risk assessment and, if needed, involve other health professionals for their advice and support.”

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

People told us they were involved in identifying and managing risks to their health, safety and wellbeing. This helped ensure risks were assessed in line with their individual circumstances and supported safe, person-centred care. Risk assessments also considered staff safety when attending care visits.

One person showed us their personalised bedroom and said, “I like my bedroom. It’s my space. Staff help me keep it clean and supported me to buy a new TV.”

The management team completed environmental assessments during the initial assessment process to identify hazards in people’s homes and reduce risks. This supported people to receive care in safe and suitable environments and showed environmental risks were managed proactively as part of wider systems for safe care and treatment.

We observed the environment had been adapted to meet people’s needs. Further improvements, including redecorating communal areas, were planned and recorded in the service action plan. As the home needed redecorating due to the age of the property. The bathrooms and kitchen had already been replaced.

The registered manager told us quotes were being obtained for garden improvements and installing a lift.

The service worked with occupational health to explore assistive technology. One person used an epilepsy monitor, enabling staff to monitor them safely at night without disturbance.

Annual premises safety checks were undertaken by an external contractor, including gas servicing, electrical checks and fire safety testing.

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.

The provider followed safer recruitment procedures and completed required checks before staff started work, including identity, references, health declarations and disclosure and barring service (DBS) checks. This supported safeguarding and helped reduce risks to people.

Records and discussions with the registered manager showed staff had the skills, qualifications and experience needed to work safely. Staff received training, supervision and development opportunities, supporting safe, person-centred care.

Staff told us they felt supported by the management team. Training records showed staff had completed key training, including safeguarding, infection prevention and control, and risk assessment, helping them identify and respond to risks appropriately.

One staff member told us, “I feel comfortable speaking to my manager, as they are very supportive. I have been given a range of training, which has helped with my development.”

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.

People and relatives told us the provider completed necessary checks before staff provided care. Personal protective equipment (PPE), including gloves, aprons and hand gel, was available for staff to use in people’s homes, supporting infection prevention and reducing the risk of cross infection. One person told us, “Staff help me to keep my room clean.”

Staff had completed infection prevention and control training and followed procedures for managing infection outbreaks. The provider completed audits and spot checks to monitor practice and ensure infection prevention measures were followed. This supported safe care and helped reduce risks to people.

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.

People told us they received their medicines safely. One person told us, “Staff remind me when I need to take my [medicine] so I take it on time.”

We reviewed people’s medicines administration records (MAR). The records reviewed were completed appropriately, with entries clearly documented, which provided assurance that medicines were administered and recorded in line with the provider’s procedures.

Regular audits were undertaken to monitor the safe handling, administration and storage of medicines. Where these identified concerns, the provider had taken action to address them.

Staff competency to administer medicines was assessed by senior staff to help ensure medicines were given safely. This provided assurance that staff had the required knowledge, skills and understanding to follow the provider’s medicines procedures in practice.