Fallowfield

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

The last rating for this key question was Requires Improvement. We found a breach of regulation of the Health and Social Care Act 2008.

At this assessment we found improvements had been made and the rating has now improved to Good. This meant people using the service were protected from abuse and 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 when required ensuring safety events were appropriately reported and managed. Lessons were learnt to continually identify and embed good practice.

There were systems in place for responding to incidents, accidents and complaints. Staff were knowledgeable about these and how to report incidents. Daily staff meetings were held providing effective communication between staff at changes in shifts. The registered manager told us daily communication with staff and during meetings and supervisions provided staff with up-to-date information about any changes in people’s needs, service improvements and any lessons learnt. Records showed that following events, the registered manager actioned changes where required, which were reviewed and monitored to ensure they were embedded and lesson learnt were shared with staff.

The provider worked with people and health and social care partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

Assessments of people’s needs, risks and wishes were completed and reviewed on a regular basis to ensure they were reflective of their needs. People told us they felt confident any health-related needs or concerns would be met and shared with health and social care professionals to promote continuity in care. A person told us, “I have a tooth that needs to come out, which will have to be done in hospital and they [staff] have arranged everything.”

Information and guidance from visiting health and social care professionals was documented within people’s care records. This ensured up to date information was available to staff when they needed it. Care plans were developed and shared with health and social care professionals when required to ensure individuals’ continued well-being. Staff worked effectively with health and social care professionals to ensure people received appropriate support when meeting their physical and mental health needs. A member of staff told us, “Handover is essential for all the team, everyone is responsible for handing over and picking up information. Care plans are easy to read; managers encourage staff to read these regularly. Changes are alerted directly on the handsets, and you have to read updates before you can proceed to use the handset at the beginning of shifts.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe with staff that supported them and staff were available when they needed them. Comments included, “They [staff] are very quick to help if it is needed and sometimes there are too many, as they can get in each other’s way”, “They [staff] are very good and put up with me when I am being cantankerous” and, “They [staff] are quick to come when you call.”

Safeguarding policies and procedures were in place and staff were trained to recognise and respond to concerns, potential abuse and harm. Staff told us they were confident any concerns would be managed appropriately. A staff member commented, “Safeguarding training here has been really good. It’s very clear on what people might experience and there’s a good culture of feeling able to report this, we can report anything and we are listened to. I have no concerns but would not hesitate to raise concern to a senior/manager if needed.”

Systems were in place to ensure robust oversight of safeguarding concerns and accidents and incidents. The registered manager showed us records and tools used to manage these, which also supported staff to learn when things went wrong. Records showed appropriate actions were taken by staff where required and good working partnerships were in place with commissioners.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of liberty Safeguard (DoLS) authorisation was applied for through the relevant local authority. All legal applications had been made in accordance with DoLS, this meant people’s rights were fully respected. The registered manager had oversight of DoLS applications, authorisations, and any conditions in place and used tools to ensure all documentation was kept in date.

Staff worked well with people to fully understand and manage identified risks by thinking holistically. Staff provided care that met people’s needs and was safe, supportive and enabled them to do the things that mattered to them. 

People were involved in assessing risks to their wellbeing and planning measures to reduce the recurrence of identified risks. A person told us, “I am involved and my [relative] too.” A relative commented, “[Loved one] was only here for a short while and we had discussions as a family with the staff, practically every day.”

Risk assessments were completed and reviewed on a regular basis supporting staff to help keep people safe. Throughout our assessment we observed staff working in line with assessments and guidance minimising identified risks. For example, when supporting people to mobilise and transfer using equipment safely. Care plans were developed following assessments and detailed individual identified risks and the actions required by staff to ensure people’s continued safety and wellbeing.

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

The design of the premises was safe and met people's needs. People and their relatives told us they liked the home environment, and it was kept clean. Comments included, “Everywhere is lovely and clean”, “Immaculate”, and “It’s always clean.”

The service was spacious, well-furnished and decorated. There were communal areas for people to enjoy and a large well maintained secure garden with suitable furniture for people to enjoy when they wished. We noted that a bathroom on the ground floor required redecorating and work on this was due to commence the week following our assessment.

The maintenance team showed us records from regular audits and safety checks they carried out in people’s rooms and equipment used throughout the service. Audits covered maintenance, health and safety, infection control and moving and hoisting equipment. Servicing and maintenance were conducted for the service’s fire alarm system, portable appliances, gas safety and legionella testing. We also saw checks and audits were carried out on the call bell system, window restrictors, water temperatures and wheelchairs.

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.

People and their relatives told us they felt there were enough staff to meet their needs, and staff were appropriately skilled and trained. Comments included, “I think they [service] have enough staff”, “There is always someone around to help”, “They [staff] are so efficient and so kind”, “They [staff] are so good that I can take it for granted”, and “Yes, they [staff] are very skilled. If they wasn’t I probably wouldn’t be here today.”

The registered manager regularly monitored call bell response times to ensure people’s needs were met promptly. They showed us staffing rotas and a dependency tool they used to determine staffing levels within the service. We observed there were enough staff deployed throughout the service to meet people’s needs in a timely manner. A staff member told us, “I think there is enough staff at all times. We work well together to ensure people get the care and support they need when they need it.”

Safe recruitment procedures were in place. Recruitment records included proof of identification, application forms with employment histories, employment references and right to work in the UK checks. Registered nurses had registration verification checks (PINs) in place. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff had the knowledge and skills required to meet people’s needs. The provider’s training matrix showed staff had completed training in areas such as diabetes, nutrition and hydration, fire safety, infection control, medication, equality and diversity, moving and handling, safeguarding, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

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.

There were effective systems and processes in place to prevent and control infections, ensuring people lived in a clean, safe, and comfortable environment. Infection control measures were effective. The environment was clean and personal protective equipment (PPE) was readily available to staff. Staff understood the importance of good infection control practices and had received appropriate training. We observed staff followed guidance on hand hygiene and safe food handling. Processes were in place to support the safe laundering of people’s clothing and items. Cleaning schedules were in place for each floor of the service to ensure the service was kept clean and free from potential infections.

Staff ensured medicines and treatments were safe and met people’s needs, capacities and preferences. People told us they received their medicines when required. Comments included, “They [staff] bring them and there are no issues”, and “All is well with the medicines.”

Medication management was reviewed in line with regulatory requirements and best practice guidelines. These included checks on how medicines are stored, administered, recorded, and reviewed, as well as how staff are trained and supported in this area.

Medicines were stored securely and room and fridge temperatures for medicine storage were monitored daily. Medicines were administered by trained staff who had completed up-to-date medication competency assessments. Staff followed the home's medication policy and received annual refresher training. Medication rounds were unhurried, and staff were observed checking MAR (Medication Administration Record) charts carefully before administering medicines. MARs were completed accurately, with clear signatures and codes for non-administration where appropriate. PRN (as required) medication protocols were in place. A robust process was in place for ordering repeat prescriptions and liaising with local pharmacies. Medicines no longer required were disposed of in line with current guidance, with records maintained.

Regular audits of medication practices were carried out by the registered manager and management team. Where issues were identified, action plans were put in place and followed up to completion.