Ontra Healthcare

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• 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. 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.

Incidents, accidents and safeguarding concerns were reported, reviewed and used to promote safer care. The provider held de briefing meetings after incidents had occurred. One staff member we spoke with told us, “We have de briefing meetings, we talk about an incident that has happened, what we could have done to prevent the incident and the learning from it.” This meant staff had the opportunity to learn from accidents and incidents and reduce the likelihood of them recurring.

Records showed that incidents were managed appropriately. Staff told us they knew how to report concerns and were knowledgeable about the processes for reporting incidents and accidents.

Accidents and incidents were analysed, and a themed analysis was created. The analysis included a summary of trends, the impact this had on people and how promptly actions were taken when incidents occurred. The management team shared the key learning identified from the analysis through team meetings and supervisions.

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.

Managers assessed people’s care and treatment needs before accepting them into the service. This ensured the provider could meet people’s needs and prepare for a safe and well‑planned transition.

The provider completed a one-page profile for people, which contained a summary of people’s needs, medical history and care requirements. This could be used in situations such as when a person was admitted to hospital ensuring a safe transition between services. Staff supported people to attend appointments where necessary.

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 were protected from the risk of abuse and avoidable harm. Staff received regular safeguarding training and had a clear understanding of their responsibility to report safeguarding concerns.

One staff member we spoke with told us, “I learnt when we are looking at safeguarding, we are looking at protecting adults from abuse, harm and neglect. I also learnt as an individual I need to report issues quickly. I also need to make sure the person is safe and I listen to the person, I need to write a factual report on what I’ve observed, and I need to tell other people in order to protect them.”

Safeguarding was regularly discussed in supervisions and team meetings. The provider had a safeguarding lead who staff could speak with if they had safeguarding concerns.

The registered manager had reported safeguarding concerns to the relevant local authority and had notified the Care Quality Commission by submitting the required statutory notification.

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 were clearly identified through personalised risk assessments and regular reviews, which were detailed, up to date and tailored to individual needs. Staff consistently followed clear guidance on managing risks relating to health, behaviours of distress, finances, medicines, independence and community access. Ensuring people were supported to take positive, proportionate risks while remaining safe.

The provider balanced risk with promoting independence and supporting people to develop life skills. For example, the registered manager told us 1 person wanted to be able to walk to the shop to buy groceries. Staff encouraged the person to walk to the shop while they walked behind at a distance. This meant the person was supported to build their confidence to walk to the shop to buy their own shopping.

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

Environmental risk assessments were in place to ensure hazards in the care environment were managed safely. This included areas such as clutter, floor conditions, pathways, handrails, lighting and fire safety to ensure people were supported in a safe environment.

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.

Recruitment checks were carried out by the provider to ensure staff were safe to work with people. Pre-employment checks included a job application form, an interview, enhanced Disclosure and Barring Service (DBS) check and references.

Staff were required to complete a full induction process as well as mandatory training and competency checks prior to starting employment, to ensure they had the knowledge and skills to undertake their duties. New staff had regular supervisions with senior leaders to monitor their progress and address any additional learning requirements.

Staff told us they were supported and received regular supervisions. Supervision records demonstrated different areas were reviewed with staff such as their wellbeing, workload and development.

Staff completed a range of training, both face to face and online. A training matrix monitored training compliance.

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.

Staff received health and safety training, which included infection prevention and control and food safety. This helped ensure staff understood how to work safely and reduce the risk of infection.

The provider had an infection control policy in place to ensure infection prevention and control were managed safely. The provider monitored staff practice through regular spot checks, which included observing hand‑washing techniques and the correct use of personal protective equipment (PPE). These checks provided assurance that staff followed safe working practices during care delivery.

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.

Medicines were managed safely, with robust systems in place to reduce risk and ensure people received their medicines as prescribed. Records showed people received their medicines as prescribed. Clear medication policies were available, and regular audits were carried out to monitor accuracy and compliance.

Staff who supported people with medicines had received medicines training and were formally signed off once they had been assessed as competent confident and capable before administering medicines independently. This meant people received safe support with their medicines by trained and competent staff.