Fallings Heath

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 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 positive culture of safety, based on openness and honesty. Lessons were learnt to continually identify and embed good practice. Relatives told us staff kept them informed of any incidents or accidents which occurred. Staff could describe the actions they took to report any incidents and how learning from incidents was shared with them. The registered manager described how any learning from incidents, audits and other systems was shared with staff in team meetings. Records we saw supported this, for example a learning log had been made to remind staff of a need to record accurately about peoples ‘as required’ medicines and reminders about requirements for recording financial transactions. There had been no safeguarding, complaints or incidents from which to draw learning, but reports for this were created monthly and these were included in the template to prompt managers to identify any learning when incidents happened.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. Relatives told us they were involved in people’s assessments, care plans and their reviews. Staff told us they were involved in supporting peoples transition to the service. The transition process involved staff spending time with the person prior to them coming into the service to get to know them and understand their needs. Staff described building up a relationship with the person over a long period of time and speaking with people who know the person well to build a picture of their needs and preferences to form their care plan. Staff confirmed key risks were assessed and plans in place ahead of admission. Staff also worked with other agencies to ensure peoples care was safe.

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 told us they felt safe living at the service and relatives confirmed they felt people were safe and would let them know if there were any concerns. Staff had received training in safeguarding and could describe for us how they would recognise the signs of abuse and the steps they would take to report any concerns. The registered manager had systems in place to track the outcome of any safeguarding referrals and could tell us how they would report and record any concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff had received training in the MCA and understood their role and responsibilities. Applications had been made to the authorising body for DoLS, and these were in place with a monitoring system to ensure these were reviewed at the appropriate time.

The provider ensured risk were considered and managed holistically. Staff provided care to meet people’s needs that was safe. Relatives told us staff supported people to maintain their safety. A relative said, “[Person’s name] has to be careful as they have started to walk leaning forwards. They take [person’s name] out to the car in a wheelchair and use this when they go out.” Staff could describe the risks to people’s safety and the steps they would take to minimise the risks. Staff could describe risks related to people’s nutrition, mobility and when they may become distressed and how they supported the individuals to reduce the risks. We saw risk assessments had been completed, these were regularly reviewed and were used to form care plans to guide staff on how to keep people safe. We saw staff followed the risk assessments for individuals during the inspection.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. A relative told us, “[Person’s name] is safe and gets good care. Every time we go the door’s locked, and there’s always somebody looking over them.” Staff told us people were able to personalise their bedrooms. We saw people had safe and comfortable rooms which they told us they were happy with. There were adapted bathrooms and toilets to support people safely. The provider did regular checks on the environment to ensure it was well maintained and risk assessments were in place to support people to maintain their safety.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Relatives told us they felt staff were well trained. A relative said, “The staff understand [person’s name] more than I do now as they’re with them 24 hours a day.” Staff told us they had an induction into their role and received regular updates to their training, records supported this. Training included medicines administration, safeguarding and specific training to guide staff in how to support people with a learning disability. A recruitment policy was in place which ensured staff were recruited safely. There were enough staff to support people safely. We saw staff were available throughout the day to support people when they needed it. Staff were observed spending time with people doing things they enjoyed and talking with people.

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. Relatives told us they felt staff understood how to minimise the risk of infection. A relative told us, “I have seen them using aprons, gloves, for various things.” The provider told us there were robust and comprehensive infection prevention and control policies and procedures in place to support infection prevention control. We saw staff used the appropriate protective equipment when delivering care and support. Staff confirmed they had received training in these procedures, and the registered manager told us regular checks were carried out on compliance, records we saw supported what we were told.

The provider made sure that medicines and treatments were safe and met people’s needs, and preferences. Relatives told us they had no concerns about how people received their medicines. We saw people received their medicines as prescribed, staff sought consent and followed safe medicines procedures when administering medicines. Medicines were stored safely and checks were in place, for example daily checks on the temperature of the storage area were completed to ensure medicines were stored safely. Medicines administration records were completed accurately by staff and there were systems in place to ensure people had enough medicines in stock. Risk assessments and care plans for medicines administration were in place to guide staff on how to administer people’s medicines. Where people had medicines prescribed on an ‘as required’ basis there were protocols in place to show staff when they should administer these medicines. Medicines administration records were in place and completed accurately. Staff told us they had received training in medicines administration and records we saw supported this.