1 Stratton Road

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 good. At this assessment the rating has remained 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 had 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, accidents and near misses were recorded with clear details of what had happened, including what people were doing in the lead up to the incident. This helped staff identify situations which could escalate people’s anxieties. Staff took a proactive approach to prevent situations escalating and minimised distress for people.

Incidents were reviewed by the management team to ensure actions were taken to reduce the risk of a repeated incident. Staff told us learning from incidents was shared with them and gave them clear information on any changes to the way they needed to support people. Comments from staff included, “Incidents are recorded and lessons learnt are discussed by the manager and we get together as a team to discuss what happened and how we can avoid it happening again”.

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.

Relatives told us the service worked well with health services people were using. People’s health conditions were documented, and they were supported to access services from a range of professionals including specialist mental health teams.

People had been supported to develop hospital passports and health action plans to ensure key information about their needs and how to meet them was shared with medical professionals if needed. People had not lived at the service very long but despite this, were happy and settled. The manager told us no-one was currently looking to move out of the service.

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.

All people told us they felt safe and listened to. One person told us staff supported them ‘in a way that is right for me’.

Staff demonstrated a good understanding of their safeguarding responsibilities and said they completed training in safeguarding adults from abuse. Staff were confident managers would take appropriate action if they reported safeguarding concerns. Staff were also aware how to raise these concerns outside of the organisation if they needed to. Safeguarding was discussed in staff meetings. The manager told us safeguarding examples were shared across the provider locations so that learning could be taken from them.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had applied to the local authority for (DoLS) authorisations where appropriate. The registered manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations. The provider was working in line with the conditions of the DoLS.

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 demonstrated a good understanding of the risks people faced and how to support them safely. Staff told us, and we saw in the records, that risk management plans were regularly reviewed and updated as people’s needs changed. This meant new health conditions or behavioural changes were addressed before they could lead to incidents. We observed staff following risk management plans throughout the visit.

One person’s care plan stated they were at risk of falls. However, the person did not have a falls risk assessment or guidance in place. We reviewed the person’s care plan and they had not had a fall since living at the care home. We spoke to the registered manager who took immediate action to draft a risk assessment for the person.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the assessment, we identified a shortfall in records held for servicing of the air source heat pump, boiler and electrical safety test certificate. This meant the provider could not be assured that essential equipment and systems had been appropriately maintained and were safe to use, placing people at potential risk of harm and demonstrating gaps in the oversight of environmental safety.

The provider completed various health and safety checks to make sure the premises, and any equipment was safe. People had personal emergency evacuation plans (PEEPS) to ensure there was information regarding how they would evacuate the home in the event of an emergency.

Feedback from relatives was the home was well maintained, with comments including, “I love how people can spend time with one another in communal areas but also if they feel overwhelmed they have the sanctuary of their own flat style living accommodation as well’. Managers confirmed this model was their preferred way of providing care accommodation for people as it ‘encourages independence as much as possible’.

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.

People told us there were enough staff available to meet their needs. Comments included: “If I want to go out, I use my 1-to-1 hours.”

Staff told us staffing levels were sufficient to meet people’s needs. Comments included, “we have a flexible rota, a lot of staff live locally so we can always pop in to take someone out for an hour or 2.” Managers confirmed this by showing us a dynamic and flexible rostering system.

Staff told us they received a good induction when they started working in the service and regular training. Staff said the training was a mix of in person and online courses, which gave them the skills and knowledge to meet people’s needs. Staff were supported to complete training relevant to people’s needs, including autism, epilepsy, communication and dysphagia. Managers had a record of training staff had completed and when any refresher training was due.

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 service was clean and smelt fresh throughout. All areas of the service were cleaned and well maintained. People were supported and encouraged to clean their own living spaces. Staff had appropriate access to personal protective equipment [PPE] and had received training on good practices of infection prevention and control. Staff told us they had all the equipment they needed and received suitable training. We saw cupboards stocked well with PPE essentials.

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.

Medicines were stored safely in people’s rooms. This meant the provider was working in line with the principles of right support, right care right culture. Medicines administration records (MARS) had been completed, with details of medicines people were supported to take. Staff received training in medicines management and records demonstrated there were regular checks for their competence in administering medicines safely. The registered manager told us there was an expectation to ensure all staff were trained in their competency with medicines at least twice a year.

The provider was signed up to STOMP (Stopping over medication of people with a learning disability and autistic people). This is a national initiative to stop over prescribing of psychotropic medicines. People had been supported to attend annual medication review meetings with their GP.