Gracefield Health Care Limited (GHC) - 31 St Domingo Grove

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

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 transparent learning culture, under pinned by openness and honesty. Staff listened to safety concerns, reported and investigated safety related events, and ensured that learning was used to drive continuous improvement in practice.

All accidents and incidents were recorded and investigated, with outcomes and lessons learned clearly documented. The service held regular meetings to review incidents, share learning, and ensure improvements were understood and embedded across the staff team.

Staff were familiar with the whistleblowing policy and told us they felt confident to raise concerns if needed. They reported they had no worries that concerns would be ignored and felt supported to speak up.

People were supported by a consistent staff team which ensured continuity.

The provider worked collaboratively with people and healthcare professionals to establish and maintain safe systems of care. These systems supported the effective oversight and management of safety and ensured that any emerging concerns were identified and addressed promptly.

Processes were in place to promote continuity of care, including during transitions between services. Staff made timely and appropriate referrals to relevant health professionals when additional assessments or interventions was required.

The service held regular meetings with the wider multiagency team to review people’s needs and to ensure that care and support continued to reflect peoples assessed needs. This collaborative approach supported consistent, person-centred care delivery.

People also had access to a consultant psychiatrist who visited the service on a weekly basis. This provided specialist input for people who were identified as needing enhanced support, helping to ensure their needs were met in a timely and coordinated way.

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 and neglect. The provider shared concerns quickly and appropriately.

All staff were aware of the safeguarding policy and their own roles and responsibilities to ensure people were safe. The provider was reporting incidents to the local authority and Care Quality Commission as required.

Relatives spoken with, told us they felt their loved ones were safe. One relative explained that other services had been unable to meet their loved one’s needs, but since moving to Gracefield they had become much more settled, and there had been a significant improvement in their mental health and wellbeing.

The provider worked with people to understand and manage risks by taking a holistic approach. Staff provided care that was safe, supportive and enabled people to do the things that mattered to them. People with more complex needs had behavioural support plans in place, which helped staff recognise triggers, respond safely and consistently, and mitigate associated risks.

However, not all risks had been fully assessed. We identified one person who was self-administering their medication, there was no risk assessment in place to ensure the risks were properly managed. We raised this with the manager on day one of the assessment and a risk assessment was implemented immediately. Whilst evidence provided to Care Quality Commission demonstrated that people’s views about their care and support had been sought, this was not always clearly documented within risk assessments. As a result, some risk assessments did not reflect people’s involvement in developing them.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. All equipment had been checked and assessed when required. Actions identified on the fire risk assessment had been completed.

The provider ensured there were enough qualified, skilled and experienced staff who received effective support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs. One staff member shared with us, “Love my job and the people we support. Great staff team.”

Safe recruitment processes were in place and followed to ensure staff were recruited safely.

All staff had completed their mandatory training, as well as additional services specific training, to ensure they could meet the needs of the people they supported.

There were enough suitably qualified staff within the service to ensure the required staffing levels were met in line with people’s dependency needs. One staff member shared, “There is enough staff on duty in general.”

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. Although the service was an old building and showed signs of wear and tear, it was clean and presentable. The housekeeping team worked hard to ensure all areas were well maintained.

The provider did not always ensure that medicines and treatments were safe or met people’s needs, capacities, and preferences. Not all risk assessments were in place to mitigate risks in relation to medicines. We discussed this with the registered manager, and a risk assessment was implemented.

For one person with complex health needs, although actions were being taken, records did not always show that staff were following protocols in line with the person’s medication care plan. This was discussed with a staff member who said they would follow this up to ensure all actions are recorded.

Medication audits were undertaken regularly. All staff responsible for administering medicines had completed the required training and had their competencies assessed.

People had their medication reviewed regularly.