18 Holt Coppice

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 service since it was registered in February 2022. 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.

There were systems in place to analyse and identify any trends relating to accidents and incidents. Any learning from events was shared with staff and measures were put in place to reduce the risk of the incident happening again. A member of staff said, “When I have raised concerns, management has listened, reviewed the information and taken appropriate action. This has included completing incident or safeguarding reports, assessing immediate risks, speaking with those involved, informing relevant professionals or family members where appropriate, and updating care plans or risk assessments. I have also received feedback and guidance about continuing to monitor and document the situation.” There was a clear commitment from management to support learning through regular training, competency assessments, and access to guidance.
 

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.

People had their needs assessed before a package of care was agreed to ensure their needs and aspirations could be met. Each person had a personalised plan to ensure they experienced a smooth transition. Risks were identified and managed proactively, and the effectiveness of these processes was monitored to maintain people’s safety. Care and support were planned with people and their representatives and healthcare professionals, to promote continuity and ensure that any transitions were well organised. A member of staff told us, “I receive an induction to the person's support needs, read their care plan and risk assessments, and receive a handover from the manager and shadow my manager or senior staff doing the call in most cases before supporting them.”
 

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 felt safe with the service provided and with the staff who supported them. A relative said, “I never have to worry about [relative]. I know they are safe and are being well looked after.”
Staff had received training about safeguarding adults and children from abuse and knew how and when to report concerns. A member of staff said, “I feel confident and professionally responsible for raising any concerns about abuse, neglect or poor practice. The safety and wellbeing of the person receiving care must always come first.” Safeguarding policies were up to date and aligned with local authority procedures. Records showed the provider shared any concerns with appropriate authorities and worked in partnership with them.
 

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.

Risks to people were assessed and a plan of care was in place to guide staff how to support people in a safe way. These included risks associated with skin integrity, nutrition and hydration, falls and managing periods of distress. People were supported by staff who knew the individual risks and assisted them in the least restrictive way possible whilst minimising the potential for harm. A relative told us, “We are kept informed about [relative] and they support him really well. Staff know the importance of ensuring they eat and drink enough.” Staff told us they had access to people’s care plans and risk assessments which were easy to follow. A member of staff said, “Care plans explain people's needs, risks, preferences, communication methods, behaviours, medical conditions and how to safely support them while promoting independence.” Another member of staff said, “Care plans and risk assessments provide information about the person’s needs, known hazards, triggers, warning signs and level of risk. I feel I have enough information to manage risk safely when these documents are detailed, current and accessible.” Staff told us any changes to people’s needs were communicated to them through daily handovers and staff meetings.
 

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

People were supported to keep their environment safe. The provider took appropriate steps to identify, assess and manage risks within and around people’s homes. Care plans contained environmental risk assessments which included vital information such as where to shut off gas, electric or water in the event of an emergency and who to contact.
 

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’s procedures for staff recruitment ensured they were recruited safely. References and checks with the Disclosure and Barring Service (DBS) were carried out before staff worked with people. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions. Staff received regular training appropriate to their role and there were regular checks on their performance and knowledge to ensure they remained skilled and competent. All new staff received a period of induction which gave them the skills and knowledge and training to meet people’s needs. New staff worked alongside more experienced staff during their induction to enable them to get to know the people they would be supporting. A member of staff said, “I completed an induction covering policies, safeguarding, health and safety, record-keeping, medication, confidentiality and person-centred care with the help of experienced staff and managers. I did shadow shifts which helped me understand people’s routines, preferences, communication methods, risks and agreed support strategies.”
 

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.

People were protected from the risks associated with the spread of infection because staff had received training and followed the provider’s procedures and best practice. People and their relatives told us staff wore appropriate personal protective equipment (PPE) such as aprons and gloves when assisting them. Staff told us they had access to sufficient supplies of PPE. There were audits and checks in place to ensure staff followed correct procedures.
 

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.

People who required support with medicines received help from staff who had received training and had their competency assessed to make sure their practice was safe. A member of staff said, “I completed medication training and competency assessments before administering medication. My competency is regularly checked.” Staff used electronic devices to record when medicines had been administered or refused. If medicines were not administered, senior staff were alerted which enabled them to take swift action. Where people received a medicine as required (PRN) there was clear person-centred guidance to support staff with administering appropriately.