Safeharbour (254 Hagley Road)

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.

Although some lessons were learnt to continually identify and embed good practice, records were not always completed to the same standard across the service.

The incident and distress recording charts were not always detailed and did not always give a full account of what had occurred. Records did not always contain enough detail to understand what had led to a person’s distress or how they had been safely supported. The management team had actions plans in place to address this and further training for staff had been planned.

Systems were in place to learn lessons from complaints and safeguarding concerns which were analysed for patterns and trends. Staff confirmed lessons learned were shared with them and they felt involved in this process.

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.

When people were due to move in, a transition plan was developed with the person and those important to them. Transition plans included meeting and spending time with other people who lived at the service and staff. This included going for tea at the home to support the person to become familiarised with the new environment and people.

Staff ensured communication between agencies was maintained and any key information was shared when people were supported by different services.

The provider worked with people to understand what being safe meant to them and with health and social care partners on the best way to achieve that. The provider shared concerns quickly and appropriately.

People had plans in place which outlined how people might react when they were anxious or distressed. These plans needed further development to ensure they included any restrictive practices that could be used when supporting people at times of distress. The provider was receptive to feedback and agreed to add the additional information to ensure staff had clear guidelines in place.

Relatives told us they thought staff supported their relatives safely. One relative said, “[Person] is safe. They have a core team to support them, and new staff will always be supervised until they get to know [person].”

Staff and leaders knew the procedures to follow if they had any concerns about people and if they were aware of any warning signs that may suggest a closed culture was developing and took action to address this. (Closed cultures are where people may be at risk of deliberate or unintentional harm, and people are not listened to.) A staff member told us, “I would raise any concerns straight away. We have safeguarding champions that we can go to if we need to.”

Staff and the records we reviewed confirmed staff had received training in relation to abuse and how to use restrictive practices safely.

When a person was deprived of their liberty, all restrictive practices were recorded in people’s Deprivation of Liberty Safeguards applications and authorisations. (People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards).

The provider worked with people to understand and manage risks, however further improvements were required to ensure records were detailed and provided clear guidance to staff.

People were supported when they were distressed. Care plans were in place to support people to have a good day, and strategies were in place to prevent distress. However reactive strategies were not always detailed to guide staff on what techniques could be used in all potential situations. The provider was receptive to this feedback and action was being taken to address this following our inspection.

Staff we spoke with understood there were times when people may become distressed. They were able to tell us what steps they took to understand and to support people to express their emotions.

People had a variety of risk assessments in place applicable to their individual needs. People who had health conditions such as epilepsy, were supported effectively to protect them from the risk of avoidable harm. Best practice guidance was followed, and the risks were identified and mitigated whilst ensuring the person was able to maintain their independence and dignity. Arelative told us, “The staff know [person] and they follow the procedures, so they know what to do, they manage [person] needs really well.”

Care plans and risk assessments were regularly reviewed when needed and when changes occurred.

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

The physical environment met people’s sensory and physical needs. Staff, people and relatives spoke positively about the physical environment and how this met people’s needs.

The provider completed risk assessments of the environment to ensure it was safe for staff and people. This included a Fire Risk Assessment and where actions were identified the provider had addressed these. Where repairs were needed action plans were in place to address these.

Relatives thought the environment met their loved ones needs. A relative told us, “[Person] room is decorated to meet their needs and preferences. A monitor is used to maintain their safety and to alert staff when support is required, we are happy and feel the environment and home is safefor them.” People had access to a sensory room which we saw had sensory items to support people’s needs.

People’s needs were met by staff who had their skills and competency assessed, and leaders had good oversight of staff skill and knowledge. Staff had undertaken training in how to support people with a learning disability and autistic people. Staff worked together well to provide safe care that met people’s individual needs.

A training programme was in place to ensure staff training was kept up to date and included training applicable to the needs of the people living at the service such as epilepsy. The provider was reviewing their training programme to ensure such training was refreshed on a regular basis. A relative told us, “The staff have the right training, skills and understanding to look after [person].”

Recruitment procedures were safe and ensured only suitable staff were employed. All required recruitment checks were undertaken before staff worked with people. A staff member told us, “I provided all the required information and had a police check before I started my induction. I worked with experienced staff and got to know people and their routines before I supported them. I have had the training I need for my role.”

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.

We saw the home was clean and hygienic throughout. Staff confirmed there was a domestic cleaner, but they also had a duty of care to ensure people lived in a clean environment at all times. Staff told us where possible people were encouraged to assist with household chores in respect of cleaning their bedrooms and after meals times to help maintain or develop their skills.

Staff confirmed they had received training in relation to infection control practices and there was enough Personal Protective Equipment (PPE) available for them to use.

The provider had an action plan in place to address any wear and tear in the home and to address any structural repairs that were required. Systems were in place to ensure cleanliness concerns were escalated so appropriate action could be taken.

Systems were in place to ensure people received their medicines safely and as required.

People were supported to take their medicines when they needed them. A relative told us, “Staff ensure [person] takes their medications. Any issues they do tell me. [Person] has regular medication reviews.” Care plans and risk assessments were in place to guide staff on how each person liked their medicines to be given. This included guidance for staff on when they could give ‘as required’ medicines such as when people expressed distressed emotions. The provider knew and followed the principles of STOMP (Stopping Over Medication of People with a learning disability, or autistic people). Where staff had concerns about the impact medication was having on a person this was escalated so that a review could be undertaken.

We saw medicines were stored safely. Staff and records confirmed they had received training, and their competency was checked to ensure they were safe to administer medicines to people. Where errors occurred, action was taken to address this.