Headzpace Therapeutic Care

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

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 72 (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 demonstrated a proactive and positive culture of safety, underpinned by openness and honesty. Staff listened to concerns and ensured safety events were investigated and reported. Lessons learned were used to drive continuous improvement and embed good practice.

Systems and processes had been introduced to review all incidents. Reflective practice records and weekly reports showed incidents were consistently reviewed to identify themes and patterns, with the aim of reducing recurrence and/or mitigating risk. Records evidenced that lessons learned were shared with staff to improve practice and enhance people’s safety, particularly where incidents reoccurred.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, where safety was effectively managed and monitored. They ensured continuity of care, including when people moved between services.

Although no new people had started using the service since the last assessment, the provider had strengthened systems and processes to support future transitions. This included a policy outlining how a comprehensive pre-assessment would be completed with the person, people who were important to them and relevant professionals involved in their care. Care and support plans had been updated to reflect detailed and accurate information about people’s healthcare needs. Guidance from healthcare professionals had been incorporated into care plans to ensure staff had clear and appropriate information to follow. There was continuity of care when people moved between different services. People had records in place that could be shared with emergency health services to ensure health partners had the required information regarding people’s care needs to ensure safe transitions.

Whilst the provider had worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns appropriately. They did concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect

Whilst some improvements had been made to the provider’s safeguarding reporting processes, including submitting CQC notifications and sharing incidents with people’s social workers. Their policy was not yet fully embedded and further work was needed to ensure incidents that meet safeguarding thresholds were reported to the local authority safeguarding team. For example, we identified incidents that met the threshold for safeguarding referral but had not been reported. A relative also told us they had not always been informed of incidents. They said, “The social worker and I fed back that I wasn’t being told about incidents, like when [person] punched the window. Now they escalate concerns to [director], who shares a report with me, the social worker and the doctor. We all need to know what’s happening, being told they are ‘fine’ is not helpful.”

Following our feedback, the provider took immediate action. They told us they had reviewed their safeguarding policy, contacted the local authority safeguarding team for advice on thresholds, and shared the relevant incidents.

People at the service were subject to Deprivation of Liberty safeguards. A deprivation of someone's liberty means thatan individual is under continuous supervision and control and is not free to leave a community setting. Court of protections were in place or had been requested where required. This meant people who lacked capacity had restrictions in place lawfully and in their best interest.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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’s personal emergency evacuation plans (PEEPs) were in place and provided staff with guidance. External health and safety checks such as, gas safety, fire risk assessment, Portable Appliance Testing had been completed. Environment risk assessment had been completed and provided staff with clear guidance.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider ensured medicines and treatments were managed safely and met people’s needs, capacity and preferences. There were medicines care plans in place which provided clear guidance for staff on how people preferred to take their medicines. Records showed medicines were administered safely. Where people were prescribed ‘as required’ (PRN) medicines, appropriate protocols were in place. Staff had completed medicines training and competency checks had been undertaken. A medicines policy provided detailed guidance for staff. Regular medicines audits were completed, and where actions were identified, records showed these had been addressed.