Barnet Mencap

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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager had a ‘lessons learned’ form which was completed and shared with staff after any incident. The registered manager shared sensitive lessons only with relevant staff.

The registered manager shared information in a bi-monthly organisation‑wide health and safety meeting and with the local authority.

The registered manager displayed openness and honesty regarding a recent General Data Protection Regulation (GDPR) concern where a cabinet was left outside with a broken lock. The registered manager identified this promptly and rectified the matter. The registered manager explained the learning included double‑checking processes, moving items safely, and staff training.

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.

During the assessment, the registered manager showed us how they process new referrals. The provider assessed new referrals covering people’s preferences, routines, communication, health, medicines and relationships. The provider reviewed these at 3, 6 and 12 weeks then annually, involving other professionals where needed.

The provider planned and managed transitions in, within and out of the service sensitively.

For people transitioning out of the service, the provider made sure a care plan and detailed handover were shared with the relevant parties.

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

The provider recorded incidents clearly with actions and follow up details. The registered manager had oversight of referrals and ensured appropriate action was taken. The provider submitted notifications which demonstrated responses appropriate for the situation and managed in line with their safeguarding process.

The registered manager and deputy manager submitted safeguarding notifications, and the registered manager reviewed all submissions to ensure completeness and accuracy.

A care worker said, “Management take matters seriously and investigate.”

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 understood people’s routines, preferences and communication needs, and used this knowledge to support people safely, including responding appropriately when alert devices, such as personal alarm watches, activated and promoting independence during daily tasks.

The provider updated detailed, person‑specific risk assessments and support plans following changes or incidents. This helped staff to manage risks in ways that reflected people’s goals and how they preferred to be supported.

People were involved in choosing meaningful activities through a regular meeting where they shared their ideas and helped plan what they wanted to do. Staff supported people to try new things safely so they could take part in the things that mattered to them.

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

The provider completed regular environmental checks and audits, including fire safety, control of substances hazardous to health [COSHH] and equipment reviews, and managers carried out home environment assessments before agreeing to support new people.

Staff monitored environmental risks whilst providing support and responded quickly when safety issues arose.

Staff escalated repair issues to the relevant housing providers. However, delays from external partners sometimes meant environmental risks remained. The provider continued to follow these up proactively.

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 gave new staff a full induction and ensured they received appropriate supervision and training. New staff shadowed experienced colleagues, and managers observed their practice and gathered feedback from people using the service. The provider maintained an up‑to‑date staff list and training matrix and ensured on‑call support was available until 10.00pm. The provider also had lone‑working safeguards, including logging home‑visit details, escalating risks to senior leaders, and contacting the police if staff did not return within an hour.

A care worker told us, “Rotas are supportive…allow time to travel safely.”

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 provider had an up to‑ ‑date infection prevention and control [IPC] policy which staff followed. The registered manager completed regular audits of cleaning and environmental checks. The registered manager ensured staff received IPC training and had access to appropriate personal protective equipment [PPE].

This meant people were protected from the risk of infection and supported in a clean, safe environment.

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 regularly audited the medication administration records [MAR] to ensure people received their medicines as prescribed.

Staff told us medicines training was consistent and comprehensive. This helped to reduce the risk of medicines errors. When a medicines error did occur, leaders addressed it through retraining and temporary removal of medicines duties, demonstrating a learning focused approach that maintained people’s safety.