Trafalgar Community Care Limited

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 66 (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, however systems required timely action to identify when learning from incidents had taken place.
For example, the providers incident and accident log recorded when incidents and accidents had occurred. However, these were not routinely analysed for patterns, trends or learning. This meant there could be missed opportunities for the organisation to learn and improve. The provider had identified this and was in process of introducing a new system.
 

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.

Pre-admission assessments and information sharing supported continuity of care when people moved between services.

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.

Staff had an awareness of safeguarding responsibilities and systems were in place to report concerns. The provider worked with external agencies to manage safeguarding risks.

People were involved in their risk assessment process and confirmed they were always consulted with verbally. However, the provider did not always record detailed levels of information within risk assessments to ensure people were kept safe and mitigated from harm. Despite this, staff were able to demonstrate a good knowledge of people’s needs.

Risk management and recording was generic in places and did not always demonstrate how risks affected people.

For instance, 1 person who had anxiety, did not have information recorded with how staff should support them with this. Whilst staff knew the person well and understood how to support them, details of the interventions by staff were not well recorded.

We fed this back to the provider, who has been responsive since our inspection, and has updated people’s risk assessments.

The provider detected and controlled risks within the environment, and systems were in place to support the delivery of safe care. Environmental risks were identified and managed through regular checks, ongoing monitoring was in place to ensure continued effectiveness.

Staffing arrangements were sufficient to ensure people were supported safely and effectively. Staff had the skills, experience or support needed to meet people’s needs consistently. There was not, however always sufficient records around training, supervision and staff recruitment. We found some minor gaps in staff recruitment records and saw supervisions were being completed informally but not always recorded. We fed this back to the provider at our inspection who has since taken action and addressed this.

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.

The provider maintained appropriate standards of cleanliness and hygiene. Staff followed infection prevention and control procedures to reduce the risk of infection and protect people from harm. There were systems in place to monitor cleanliness, although continued oversight was required to ensure these were consistently embedded in practice.

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, and systems were in place to support safe administration and monitoring. Staff followed processes to administer medicines, and checks were carried out to identify issues.