Ventura

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

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 positive culture of safety; however, incidents and lessons learnt were not always well documented to record actions, identify learning and embed good practice. People, relatives and staff told us they felt able to raise any concerns with the registered managers and were confident these would be dealt with sensitively and appropriately. A person said, “Never had a trouble, yes absolutely.” A staff member said, “Registered Manager would listen to me.” Staff reported and documented accidents and incidents and understood their responsibilities to record events and monitor people to ensure their safety. However, we found some incident records were not reviewed or signed off by management in a timely way. Although immediate actions were taken to manage risk, these were not always well recorded. We raised this with the management team, who told us they would take steps to ensure incident records were reviewed and completed without delay. Staff and managers told us incidents and lessons learned were discussed during daily handover meetings; however, we found learning was not always well documented.

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 provider planned and organised care and support with people in ways ensuring continuity. People were assessed to confirm the service could meet their needs before admission. The provider had procedures to support staff with new referrals and when working alongside other professionals. Professionals we contacted told us communication was effective and working relationships were positive, which supported continuity of care for people. A professional said, “The support staff have been very responsive to [persons] needs and wishes. Communication during the time of settling in was good and I was able to reach out to the staff when needed.” People and their relatives told us health professionals were involved in their care when required. A relative said, “Relative always tells me that medicines are sorted and appointments, they are on top of things.”

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. People and their relatives told us they felt safe living at the service and could raise any concerns with staff. A person said, “Oh yeah, very safe.” We observed people felt comfortable and at home within the service. The provider told us they maintained a regular presence at the service, which enabled them to monitor interactions between people and staff. While some incidents were not always reviewed or signed off by management in a timely way, appropriate referrals were made in response to safeguarding concerns. This included informing the local authority safeguarding team and notifying CQC as required. The registered manager explained how they had addressed a recent safeguarding concern, including actions taken to reduce risk. The provider had an appropriate safeguarding policy providing staff clear guidance on how to safeguard people from abuse. Staff had received training in safeguarding adults, understood their responsibilities in relation to safeguarding, and were clear on how to report any concerns. People can only be deprived of their liberty to receive care and treatment when there is appropriate legal authority. In care homes, this is done through a process called the Deprivation of Liberty Safeguards (DoLS), which forms part of the Mental Capacity Act 2005. At the time of the assessment, no person living at the service was subject to a DoLS authorisation.

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. Since the last inspection, the provider had made improvements in assessing and monitoring people's risks, for example in relation to diabetes and self-neglect. Care records contained clear and up to date risk assessments. These were detailed, person-centred and provided guidance to staff for managing risks. People’s care records had recently been reviewed by the management team. Staff understood people’s risks and communicated any changes in handover meetings. There was evidence of positive risk taking, the service offered opportunities for people to live more independently within two self-contained flats. The provider shared examples of how the service supported people to access the local community independently and participate in group activities. Professionals we contacted who work with the service spoke positively of their experience. A professional said, “Risk assessing and taking seems to be dynamic and the team appear well managed. The team seem knowledgeable about the resident’s needs.”

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. Some environmental shortfalls identified during the previous inspection had been addressed. For example, window restrictors were installed, areas of the service were redecorated, and most radiators within the premises were now covered. However, we identified further areas requiring improvement. Records of water temperature checks showed temperatures regularly exceeded 44 degrees celsius, contrary to Health and Safety Executive guidance. The service had not taken sufficient action to reduce water temperatures, which placed people at increased risk of scalding. The provider responded promptly to our concerns and arranged for the installation of systems to better control water temperatures and to cover the remaining radiators. The provider carried out other building safety and equipment checks, including gas, fire, and electrical checks, to ensure the safety of people living in the service. These records were satisfactory. Despite the shortfalls identified, people, relatives, and staff told us the premises were well maintained. A staff member said, “Yes, if we report something, [the provider] will get someone in to fix it.”

The provider made sure there were enough skilled and experienced staff, however, they did not always make sure staff received effective support, supervision and development. Procedures were available to guide staff in carrying out safe recruitment practices. These included obtaining Disclosure and Barring Service (DBS) checks, references from previous employment, and a full employment history. However, we identified some gaps in the recruitment records we reviewed. Gaps in employment history and reasons for leaving previous roles were not always explored or documented. People and their relatives spoke positively about the support they received from staff. A person said, “Staff are helpful, and yes they listen.” Most people, relatives and staff said there were usually enough staff available to meet people’s needs. A person commented, “There’s quite a few of them, I can speak to them.” However, some staff felt staffing levels needed to increase. We discussed this with the provider who told us they had identified this, and staffing hours were due to increase from the following week. We observed there were enough staff available to meet people’s needs. The staff team was well-established, knew people well, and appeared competent. A relative commented, “Yes, I think the staff are very skilled.” Staff told us they felt well supported by the management team and records confirmed they had completed an induction and the provider’s mandatory training before starting work at the service. A staff member said, “I’m happy, I feel supported.” Staff were receiving supervision and an annual appraisal; however, we noted supervision sessions were not always taking place at the frequency outlined in the provider’s procedure. The provider had systems to monitor staff compliance with mandatory training, as well as training to meet the individual needs of people using the service. We raised the shortfalls identified with the management team, who told us they would make improvements.

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 made improvements since the last inspection to ensure risks relating to infection control were assessed and managed effectively. Overall, the provider maintained a clean service environment, and records confirmed regular cleaning took place. The infection prevention and control policy had been reviewed, and regular audits were now being completed. Staff conducted regular environmental walkarounds to help ensure cleaning standards were maintained. We observed personal protective equipment (PPE) was available and used appropriately. People told us the service was kept clean and staff supported them to participate in the process. A person said, “I have responsibility to keep my flat clean. [staff] clean it as well.” A relative commented, “Yes, whenever I visit it looks well kept.”

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. Systems ensured people received their medicine as prescribed. We reviewed medicines administration records for some people and found the recorded stock levels matched the medicines in place. People and their relatives spoke positively of the support provided with medicines. A person said, “Yeah, pretty good [medicines] at teatime and in the morning.” A relative said, “All good. They keep me up to date with any changes with [person’s] permission.” Staff stored medicines safely and securely. Staff had completed medicines training; however, not all staff had their competency refreshed during the past year, in line with national guidance. During the assessment, the provider acted promptly to update staff competency assessments.