Coalway Lane

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 the last inspection we rated this key question good. At this inspection the rating has remained 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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. We found the quality and safety team, clinical leadership teams and management team within the service constantly reviewed the operation of the service, and actively made changes as and when these were needed. Following a review by the provider’s health and safety team the incident monitoring records had been developed to give greater scope of information. The changes allowed more flexibility for staff to understand themes, reasons for the events and lessons, which could be learned. These changes to the way they monitored services meant they could readily identify even minor changes in practice and use the information to complete deep dives into the service. This had led to a wide range of improvements, including to medicine management. The head of specialist nursing, registered manager and clinical lead also used this information and what they gathered directly when operating the service to constantly look where lessons could be learnt and make improvements. For example, they had reviewed the use of the induction tool, which was specifically designed for use within the nursing services. They found the newly employed domestic service contractors were not asking staff to complete this. The team deemed it was an essential requirement and ensured these staff also undertook the induction. A staff member said, “We are always looking for how we can make improvement. We have changed how we think about learning lessons; from considering it only used to blame people to what it always should be a way to help us look for areas we can make improvements.”

Staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They worked closely with the crisis team and hospital staff teams to ensure people were only admitted when they were confident the service could meet the individual’s needs. They made sure there was continuity of care, including when people moved between different services. People reported this level of service had enhanced their quality of life. A person said, “The staff talked to me about the service and I’ve come to look around to see if I want to stay here. I think it will be a great place to stay while I sort myself out and deal with the issues I’ve had.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. No one was subject to DoLS authorisations, but the management team understood when these would need to be sought and what to do if there were conditions imposed. Some people were subject to the powers of Mental Health Act 1983 (amended 2007) and were required to meet the requirement of conditional discharges and community treatment orders. The staff had a good understanding of how to ensure these requirements were met.

Staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place and assisted staff to identify how to mitigate risks. A new electronic record system had recently been introduced and staff were in the process of moving information on to this system. Whilst doing this piece of work they were reviewing all the risk assessment records to ensure they were very clear and easily understood by staff and the people who used the service. People felt confident staff understood them and could support them to manage any risks posed. A person said, “Since I have been working with the staff here, I have found ways to manage the difficulties I face in better ways and my risky behaviour has reduced an awful lot.”

The provider had not always detected and controlled potential risks in the care environment. We found, in the unit containing crisis beds, the door handles on bedrooms at one side of the unit were designed to reduce the risk of people tying ligatures to them but not on the other. The risk of people self-harming via strangulation were the same on either side of the unit so it was unclear why ligature proof door handles were not in place across the unit. We raised this with the registered manager, and this was immediately addressed. They made sure equipment, facilities and technology supported the delivery of safe care and worked with external professionals to review people’s aides. People were supported to be as independent as possible within the environment. The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed.

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 nature of the service meant staff deployment needed to be very flexible. Generally, there were enough core staff in place to ensure people’s needs were met and additional staff could be readily obtained. At times when people became seriously unwell there could be delays in obtaining the staff needed to cover the duration of the crisis. The management team were aware of the difficulties surrounding the unpredictable nature of people’s needs on designing a staffing dependency tool. They were currently completing a comprehensive review of the staffing tools they used to ensure they are sensitive to the flexibility of the service needs. A staff member said, “The staffing levels are adequate.” A professional said, “We have never found issues with staffing levels and, when needed, additional staff are quickly deployed.”

Recruitment practices were meeting requirements. The people’s team had developed robust training programme, which was effectively delivered, and they consistently evaluated its effectiveness. The team considered the impact this training had on how staff delivered the service and whether it was embedded into their practices. They consistently looked to see it assisted staff to effectively support people to improve their mental health and supported the organisation to embed the overriding culture of ‘Here so no one struggles alone.’ The provider offered access to additional training including access to nurse training, apprenticeships, preceptorship and mentoring programmes. The nursing team within Coalway Lane also ran clinical reflective groups, which assisted them to meet the requirements for continued registration with the Nursing Midwifery Council.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed the required infection control guidelines. Recently the domestic services had been contracted out to an external provider and the management team were working with them to ensure they mirrored the previous standards. A person said, “We keep on top of our rooms but the domestic staff are great at making sure everything is kept very clean and fresh.”

Staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff who administered medicines had the appropriate training and competency checks. The design of the service meant the client group frequently changed and staff were constantly admitting people who needed medication. To manage the constant flux, staff routinely completed checks to ensure the correct amount of medicine had been administered and followed up immediately any missed signatures. The clinical lead completed various in-depth audits on a weekly and monthly basis. These practices ensured staff managed medicines safely.