Lister Avenue

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 was a learning culture in the care home. Staff were aware of procedures to follow to report and record incidents. We saw accidents and incidents were reviewed and analysed to identify themes and trends. Feedback to the staff team was provided through daily flash meetings and regular team meetings. Staff told us communication was very good, and they were listened to ensuring lessons were learnt.

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. We saw evidence in care plans of visits and referrals when required and information was shared and reviewed to ensure people’s needs were met. People confirmed this, for example, one person explained they had some medical issues, and an appointment was made with a specialist team, information was shared and they were satisfied with the outcome.

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 registered manager shared concerns quickly and appropriately. Staff understood safeguarding procedures and reported incidents immediately to management. Staff were confident the registered manager would respond appropriately. People we spoke with told us they felt safe. One person said, “I do feel safe here.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People's capacity was assessed in line with MCA and decisions were made, where people did not have capacity, in their best interest. People had Deprivation of Liberty Safeguards (DoLS) in place to protect their rights and the service complied with these.

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 which mattered to them. Risks associated with people's care were identified and managed effectively. The registered manager told us, “We develop risk assessments and risk management plans for people. We work with the person and care team to complete the plans. The project leads will conduct an audit on these monthly and if there are any issues then they will discuss with the keyworker.” We saw risk assessments were in place and regularly reviewed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. A redecoration plan was in place and decoration of all communal areas had been approved and were awaiting a start date. Appropriate checks of the environment and associated services, including fire, water and equipment, had been completed and were reviewed by the provider. However, we identified the designated smoking areas was small and cramped, there were also several bicycles stored in the same area. One person said, “I don’t like the smoking area, it is dangerous when it gets busy because we have to step over each other, one person crosses their legs, and I have to step over them. It is an accident waiting to happen. There are 9 people that smoke, and we sit on 2 benches and 2 chairs, it’s not good.” Following our site visit, the registered manager sent us pictures to show this has been decluttered and reorganised to ensure peoples safety.

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 which met people’s individual needs. Members of staff were recruited safely and there were sufficient staff to meet people’s care and support needs. Two new members of staff were able to tell us how they were recruited which followed a robust process. One staff member said, “I had a very good induction, we are very well supported.” Some staff said they would benefit from some specific training in managing behaviours that could challenge, we discussed this with the registered manager, who said this had been raised by staff and was being organised.

Staffing levels were determined by the needs of the people who used the service. Staff told us, there had been new staff commence in the last few weeks, and this had improved the staffing. One staff member said, “The staffing levels have improved, this means we can organise more activities for people.” People told us there were, predominantly, enough staff on duty. One person said, “There are usually enough staff, occasionally they can be short, but it seems to be better lately.” Another person said, “There are plenty of staff around and they keep an eye on everything and sort things out if there is a problem with someone.”

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. However, some areas of the environment were not well maintained so were not able to be effectively cleaned. These included bathrooms, kitchen units, refrigerators, freezers, store cupboards and untreated wooden shelves. The registered manager assured us following the visit that the kitchen refrigerators and freezers had been thoroughly cleaned and were waiting quotes for new seals or replacement equipment. The improvements to bathrooms were being addressed by the provider. However, the work was not due to commence until the 2025/2026 financial year. The registered manager assured us in the interim these would receive a deep clean. Staff had access to appropriate stores of personal protective equipment (PPE). Members of staff had access to infection prevention and control policies. Audits we reviewed, identified areas for improvement and the provider had an environmental action plan that was being followed to make improvements.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning where appropriate, including when changes happened. Administration of medications was managed safely. Members of staff had access to policies and procedures which supported safe clinical practice. Staff were knowledgeable on peoples’ medicines and specific requirements. Staff were trained and received competency checks. We observed staff administering medicines safely and staff were able to explain people’s needs. However, there had been a very recent change in the dispensing pharmacy and there had been a number of issues. For example, people’s medicines prescribed for use ‘as and when required’ were not recorded on the medicine administration record [MAR]. Staff had not properly recorded receipt of medicines and no carried over amounts were recorded on the MAR. The audits of medication administration had identified this and the registered manager was working with the new dispensing pharmacy and staff to ensure errors were rectified. We did not find any evidence people were not receiving medicines as prescribed, it was a documentation issue and it was being addressed. Following our site visit we received evidence from the registered manager confirming all issues had been rectified.