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• 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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Significant improvements had been made, and the provider was no longer in breach of this regulation.

This service scored 66 (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. The provider had identified the recording of accidents and incidents did not give them the detail they needed to make improvements and learn from incidents. They worked with staff to improve their competence in recording which had enabled managers to accurately review incidents for patterns and themes to help prevent future occurrences.

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. Staff provided healthcare teams and hospitals with the written information they needed to provide care that met people’s needs. A visiting health professional told us, “Staff are very good, they carry out all the [diabetic recordings] prior to my visits.”

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. Staff had received safeguarding training and knew when to report their concerns. The provider had systems in place to record, report and act upon safeguarding concerns. Systems were being developed to identify and embed good practice to prevent people from acquiring skin tear injuries and improving communication with relatives.

The provider had applied to Deprivation of Liberty safeguards (DoLS) where required and followed the conditions imposed.

The provider did not always work with people to understand and manage risks by thinking holistically. People had not always been involved in assessing and mitigating their known risks such as falls. However, some people who went out of the home regularly were involved in their assessments. Relatives told us they had been involved with initial assessments when people were admitted but had not been involved in subsequent reviews. We brought this to the attention of the provider who demonstrated how they were going to incorporate people in managing their risks as they transfer their electronic care planning systems over in the near future.

The provider did not always detect and control potential risks in the care environment. For example, the provider’s audits and manager’s daily checks had not identified two fire doors that did not close. We brought this to the attention of the provider who arranged for the maintenance staff to repair the doors the same day. They made sure equipment, facilities and technology supported the delivery of safe care. Staff told us, “We check the general condition of equipment every time we use it.” There were effective processes to manage and audit and water safety.

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 was developing a new nurse and senior care team which was led by the current temporary clinical lead. The provider recognised the need for a permanent full time clinical lead and was in the process of recruiting them. The provider had moved all people to the ground floor. A relative told us, “There’s enough staff now they’re all downstairs. At the weekend it can seem there more stretched.”

The provider did not always manage the risk of infection. During the inspection we observed staff did not always wash their hands or change their personal protective equipment after providing personal care or handling soiled bedding. We brought this to the attention of the manager who arranged for an immediate all staff supervision to ensure staff understanding of infection prevention and control. The provider had systems to detect and controlled the risk infection spreading and shared concerns with appropriate agencies promptly.

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. The provider had implemented an electronic medicines administration system which their audits had identified had improved the safety of the medicines management. A person told us, “Staff tell me what the tablets are, they put them on the side for me, and I take them myself. Staff stay around to see they are taken.” Where people required their medicines covertly (without them knowing), there were safeguards in place to ensure a best interest meeting had been held with the GP, managers and relatives and pharmacy advice sought. A relative told us, “[Staff] give [Name] medication covertly in their yoghurt, I had a letter about it.”