Flora Innes House

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 assessment we rated this key question as Good. At thisassessmentthis rating has changed to Outstanding.

This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This meant people were safe and protected from avoidable harm.

This service scored 88 (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 fostered an exceptionally strong, proactive and deeply embedded culture of safety, characterised by openness, honesty and a clear commitment to continual learning. Staff consistently listened to and acted on any safety concerns, and safety related events were investigated thoroughly and transparently. We saw where lessons learned were not only shared but were systematically embedded into everyday practice, demonstrating a robust approach to sustaining high quality, safe care. An example of this was when a person had been learning to go out in the local community independently. An incident occurred which may have caused harm. The registered manager and staff worked together with the person and external agencies to ensure lessons were learnt and some actions were put into place. These did not stop the persons independence but enabled a additional positive risk assessments to be implemented. This meant the person was still able to be independent carrying out the activity.

The managers of the service attend forums and sometimes worked across other services run by the provider, so they can obtain different learning opportunities. They communicated any findings/innovative approaches to care, to each other and the staff teams.

We saw feedback forms from staff, relatives, and external professionals which were sent out regularly. Any comments were listened to and acted upon. An example of this was when a person had become uncomfortable with the use of social media messaging service. This was acted upon in a timely manner. This meant the person felt listened to when they raised a concern and would be likely to feel able to again if needed.

Staff demonstrated a clear, values driven commitment to achieving positive outcomes for people. We saw full quarterly monitoring from managers including welfare and updates of people, and incidents/lessons learned. Staff used outcomes of this monitoring in their keyworker meetings with people to ensure safety and progress was continual.

Staff reported feeling exceptionally well supported and confident to raise concerns, knowing these would be responded to promptly and effectively. They had access to high quality, role specific training, ensuring they could meet people’s needs safely and competently. Records showed staff had a strong understanding of incident reporting, and the management team consistently met their duty of candour responsibilities by being open, transparent and timely when things went wrong. One relative told us “If there are any issues, I would always be updated”

Risk was approached proactively. Risks were never overlooked; instead, they were treated as important opportunities to strengthen practice, improve outcomes and prevent recurrence. Team meeting minutes included clear reflections on what was working well and concerns, alongside documented action plans, and daily handovers. This ensured potential issues were identified in real time and meant peoples care and support was adapted in a timely way to reduce risks to them.

We saw where the manager encouraged staff to support people doing things independently, and staff checked afterwards to see if there was anything to be learned. The staff had communication app so any incidents and lessons learned could be shared instantly.

The registered manager advised us that “We have also been taking full advantage of the training from the community training partnership”. This is a training initiative offered by the local authority.

Staff told us they felt able to say if they thought something could be improved. Their views and any concerns would be listened to and acted upon if necessary.

Staff clearly understood their responsibilities around openness and incident reporting. Learning from incidents was routinely explored in team meetings, and the management team undertook reflective reviews to identify emerging themes or patterns, ensuring preventative action could be taken swiftly. We also saw clear evidence of learning from complaints, demonstrating the service’s ongoing commitment to improvement, accountability and high quality, safe care.

This meant an active and open learning culture was embedded in the service, which supported positive risk taking, and continual reflection.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

Hospital passports were made available and part of emergency procedures. We observed these to be well laid out so information could be found urgently if needed. They described people in thorough and respectful ways and showed a real understanding of who the person was. Staff used their understanding of a person they support to identify a potential urgent medical need. External clinical staff advised us “The staff acted promptly, ensuring (they) was taken to hospital without delay”.

Staff used their in-depth knowledge of a person to identify and act on subtle hanging health needs. An external health professional told us that during an outpatient appointment the staff member with them “Demonstrated an excellent understanding of the service user’s needs and provided thorough, up-to-date information regarding(their)care and progress.”

We saw evidence of the process when somebody is referred to the service. People and their relatives were involved initial care planning, and consideration was given to the needs of the person throughout the transition.

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that.
Staff had a very clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. One health professional told us that families they had spoken to “Appreciate knowing their loved ones are safe and supported.”
There was a clear understanding of the requirements of the Mental Capacity Act (MCA), and staff demonstrated how they embedded the principles into their practice effectively, to ensure people were supported to understand risks and make decisions. There was a clear policy for safeguarding. Staff understood the processes in place, and their role in this, to keep people safe.
We observed people were relaxed around staff and felt able to speak about any worries they were having. People were able to tell us they felt safe living in Flora Innes House, and they appeared happy to have these conversations with us and show us around their rooms. Staff had explained to people prior to the inspection who we were and why we were there which helped them to feel safe to liaise with us.
The manager understood the importance of people feeling safe around external partners. Efforts had been made to develop close links with the GP surgery, nursing staff, and wider healthcare professionals. We saw plans where somebody was being helped to desensitise their fear of needles, which was making their appointments less stressful for them. However, we also saw where a person had become fearful of not seeing their clinician regularly, even when it was not medically indicated. The person now felt safe enough to instigate their own discharge from the clinical service. They had not needed any PRN (as needed) medication for anxiety since they had moved into the service as they spent time talking to the staff instead if they felt anxious.
There were risk management policies, procedures and practices that aimed to minimise any restrictions on people’s freedom, choice and control. We saw how the provider had understood safeguarding and restrictive practices to proactively work to safely reduce the number of staff support a person needed, sometimes down to no support with specific risk assessed activities. This ensured people maintained maximum independence and safety.
Staff told us they understood it was important to find innovative ways to explain situations around consent to people. One said, “I ask for consent using simple words, gestures, and body language to make sure the person agrees and understands”. They also told us they understood why some restrictions were necessary when accessing the community so that, “The [people] stay involved in the activities they choose and enjoy doing to promote and support their independence and wellbeing”.
We saw records which showed that the provider was aware of some situations in which an increase in staffing might be required. This personalised and least restrictive approach reflected a strong safeguarding culture and exceptional understanding of people’s individual needs.
We saw staff meeting minutes which evidenced safeguarding was embedded and discussed in all team meetings. This helped to ensure that staff were very knowledgeable about safeguarding policies and procedures and felt able to raise and discuss any concerns. Staff fully supported people to be involved in understanding risks and how to keep safe. For example, they used a pictorial system to explain to a person the importance of sleep hygiene to reduce known risks to them. A person who was going out independently, had learned how to use a tracking app and how this could be used to support their freedom and safety and so they could make contact immediately with staff if they needed to. Electronic data management ensured all new related policies were read and understood.
We saw MCA paperwork in place which was thorough and meaningful to the person with relatives’ involvement. Risk assessments were fully personalised and clear for staff to understand and follow. This included steps to take in the event of emergencies e.g. electronic entrance break down.
A relative told us they knew their person felt safe as they no longer phoned them all the time for no reason. They were “very settled” now and called regularly but appropriately.
 

People were fully involved in understanding and managing risks in ways that promoted their independence, dignity and personal choice.
Risk assessments were in place which were clear for care staff to understand, use on a day today basis, and explain to others. We saw risk assessments which were thoughtful, person centred and designed to keep people safe, while remaining proportionate and regularly reviewed with the person or their relative and health professionals. Managers had good oversight of these and monitored them to make sure they were fully understood.
The service was exceptional at encouraging people to take carefully managed risks to live fulfilling and meaningful lives. This demonstrated a proactive, practical approach to safety without limiting people's independence or daily experiences. Staff used accessible communication tools to help people understand potential risks and make decisions. Staff told us they felt they have had good training and guidance to help them understand and support people in taking positive risks.
The manager told us that a key achievement of the service is the support and development of everyone. We saw evidence of a person who had moved into the service with low confidence and a low level of independence skills. By assessing their needs, risk assessing, and following their requests, the person is now able to “cook for themselves, self-administer their medications, ordering and collecting their medication, using public transport, made new friends, found work and hobbies they enjoy, and found their voice”. We spoke to the relative of the person who told us, “(Person) is doing very well and now catches the bus. They have given (person) a flat which has put (person) on the path to independence with support. (They) are so settled”.
Staff told us, “Positive risks are taken all the time here with our ethos focussing on independence, choice, and empowerment.”
 

People were cared for in a safe environment that had been thoughtfully designed and adapted to meet their individual needs, preferences, and sensory profiles. We saw that the building had been renovated to make it more suitable for people to use all of it independently, and staff had enough space to carry out their roles.

People had areas where they could sit together if they wished to but also had their own rooms they could independently access whenever they needed to. The home was fully accessible other than areas which had restricted areas for safety purposes e.g. COSHH (Control of substances hazardous to health) cupboards. A stairlift was in place to meet long-term needs. We saw this was regularly maintained, and there were step by step instructions of how it should be safely used.

The service ensured that the environment promoted independence, safety and emotional wellbeing. There were pictorial communication methods to tell people what was in cupboards, and what rooms were used for. There was an open-door policy to the accessible managers room, and we observed people using this freely to engage with staff or show off their belongings.

The environment was also safe for staff to work in without restrictions to their ability to offer care. Staff told us they felt confident that risk assessments, safety checks and clear guidance ensured they could work effectively and safely. We saw audits which were carried out daily, weekly, or monthly with people who understood their responsibilities with carrying these out. If any environmental concerns were noted, we observed these were rectified in a timely manner.

The size, setting and design of the service aligned with best practice and relevant legislation, ensuring the home was accessible, appropriate and adaptable for current and future needs. This significantly improved people's comfort, sense of safety, and overall quality of life. Where possible people were consulted about the environment to ensure adaptations and reasonable adjustments were made to meet their individual needs. One relative told us, “There is a beautiful feeling about the place”.

There were effective fire safety procedures in place. We saw audits and safety policies in relation to COSHH. Carers had training in safety procedures and knew how to request any maintenance needs. We saw evidence of spot checks where any issues were identified and managed in a timely manner.

This consistent commitment to safe, personalised and future‑proof environments demonstrated the provider’s understanding of how physical surroundings directly influence people’s wellbeing ,independence and day‑to‑day experiences.

The service understood the importance of safe and effective staffing, ensuring people consistently received high-quality, person-centred support from staff who understood their needs well. Staffing levels were proactive, flexible and based on people’s assessed needs rather than set routines, ensuring staff were always available to provide the right support at the right time.
This reflected the principles of Right Support, Right Care, Right Culture, ensuring the right mix of staff skills, experience and values were in place to deliver truly personalised care that promoted independence, dignity and choice.
Staff were recruited safely, with robust checks and interviews to ensure new team members demonstrated compassion, respect and a commitment to supporting people with a learning disability.
People benefited from consistent staffing teams which reduced anxiety and helped to build trusting, secure relationships. Staff told us they felt well trained and confident in their roles, and we saw evidence of high-quality induction, ongoing supervision and specialist training, such as positive behaviour support, communication approaches and sensory awareness which enabled staff to support the person safely and effectively. Training was tailored to the needs of the individual. Staff had completed the mandatory training requirement on learning disability and autism in line with code of practice. The provider encouraged staff to develop and progress in their careers.
The service regularly reviewed staffing levels and skill mix, adapting to changes in people’s needs or circumstances to ensure risks continued to be managed safely and people’s daily lives were not restricted. Staff deployment was thoughtful and well planned, ensuring people received support from those who knew them best and could recognise subtle changes in behaviour, mood or health. Relatives and professionals consistently praised the service for its knowledgeable, skilled and reliable staff team.
Staff told us the managers were approachable and always willing to help them. They said the managers, “Led by example”, and they had no concerns about asking for help with something if they were unsure.
Staff were encouraged to request any training they felt they needed.
This strong commitment to having the right people, in the right roles, working in the right way meant people experienced safe, high-quality care delivered in an environment where their individuality, rights and aspirations were always prioritised.
 

The service had effective infection, prevention and control (IPC) measures in place to protect people, staff and visitors from the risk of infection.

Staff followed clear policies and procedures that aligned with current guidance, and they demonstrated a good understanding of how to reduce the spread of infection. Regular cleaning schedules were in place and monitored, ensuring environments remained hygienic and well maintained. Staff used personal protective equipment (PPE) appropriately if needed. Training in IPC was up to date.

We saw care records which showed people were encouraged to take part in keeping their home clean and safe. We saw that people were proud to show us their rooms and where they were cleaning supported by staff. One person told us their relative had “Changed very much for the better, (they) clean (their) room”.

Staff were nominated to be IPC champions. The manager advised us they worked closely with the local authority who provided regular training for the champions.

The provider carried out regular audits to ensure standards remained high and acted promptly when improvements were identified. These measures ensured people experienced safe, clean and comfortable living environments. We saw weekly environmental cleanliness audits as well as posters to remind people of safety measures such as hand washing.

We saw policies and procedures on infection control and a full continuity plan to deal with outbreaks within the house if needed.

The service had safe and effective systems in place to support people with their medicines. There was an exceptionally person-centred approach to support people to take their medicines. Some people living at the service were extremely well supported by staff to self-administer and manage their own medicines when they were safely able to do so. Staff told us they had enabled somebody to learn how to manage their own use of paracetamol and ibuprofen, which the person had said they felt proud to be able to do. We saw clear policies and procedures that proactively promoted safe administration, storage and recording of medicine. People's care plans had up to date information about how to support them with their medicines.

Medicines administration records (MARs) were completed accurately, and audits were carried out regularly to identify and address any gaps or errors. The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people or their relatives in planning medicines, including when changes happened.

PRN (as‑needed) medicines were detailed and robust, with clear protocols in place that explained when they should be given, how to recognise when the person might need them, and any alternatives staff should try first. These protocols were detailed enough to ensure consistency between staff and helped reduce the risk of unnecessary medicine use. Staff demonstrated a good understanding of how to monitor the effectiveness of PRN medicines and when to seek professional advice.

The service had a clear awareness of STOMP (Stopping Overmedication of People with a Learning Disability, Autism or both) and promoted its principles in practice. Staff worked closely with health professionals to ensure medication was reviewed regularly. One external health professional told us they “Work to improve residents' ability to manage their own medication”.

The service followed the rules of safe medicines management that are provided in NICE (National Institute for Health and Care) guidance. Staff were able to explain these to us. This means there was a consistent and safe approach to medicines management.

Relatives and professionals told us they felt medicines were managed safely and that staff were knowledgeable and proactive in keeping people well. Staff demonstrated they knew what to do in the event of a medicine error and would not be worried to tell the managers what had happened.

These measures ensured medicines were administered safely, reviewed appropriately and used in a way that actively promoted people’s health, rights and overall wellbeing.