Tikvah Woodpeckers

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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were recorded and monitored which helped to identify any themes or trends. The registered manager told us they shared learning with staff to reduce risk of recurrence. A member of staff told us they were informed and updated by the management of investigations and outcomes of accidents and incidents.

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. The registered manager told us they would conduct initial assessments and action transition plans if people were moving to the service. They would ensure the transition plans were person-centred, in line with people’s wishes and implement the transition plans as desired by people. Care records and assessments were up to date which supported safe decision making if people needed to move between services. People had hospital passports which included important information such as preferred communication needs, to be shared with hospital staff to ensure people’s needs would continue to be met.

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.

The registered manager understood their responsibilities when submitting notifications to CQC and informing the local authority of safeguarding concerns. Safeguarding concerns were recorded and monitored which helped to identify any themes or trends. The registered manager told us they shared learning with staff to reduce risk of recurrence. The provider had a safeguarding policy and procedure. Staff completed safeguarding training and could describe how they implemented this in practice. Relatives told us people were safe and people were supported by familiar staff, many of which had worked at the service for a long time.
 

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

People had risk assessments in place, including for, personal care, skin integrity, creams and anxiety. Staff followed guidance to support people in a safe way and minimise the potential risk for harm. Staff we observed understood how to support people appropriately in line with their assessed needs and risk management plans. For example, when providing personal care support and when people became distressed. Daily handovers were completed to support staff with regular updates on any changes to people’s needs. The registered manager told us they focussed on recognising and understanding people’s needs to reduce risks to people. For example, risks associated with creams, mobility and nutrition.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People lived in a comfortable environment where there was no malodour. People’s rooms were personalised in accordance with their tastes and preferences. Regular health and safety checks were completed such as, fire risk assessments and wheelchair checks, to ensure people remained safe. The provider had a business continuity plan to manage unforeseen circumstances such as adverse weather. Relatives told us the home was nicely designed with lovely gardens which people benefited from, and people were comfortable in the home.

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.

We observed a good staff presence during our visits and people did not have to wait for assistance. Staff were recruited safely and records included the required pre-employment checks. The provider completed Disclosure and Barring Service (DBS) checks before staff could work unsupervised. A DBS check is a criminal record check used by employers to help them make safer staffing decisions.

Staff supervisions and appraisals were completed and staff received regular training appropriate to their role. The registered manager told us if skills development were identified, staff were supported to build their confidence in supporting people. Relatives told us there were enough staff in the home to support people and people were supported by confident and skilled staff who knew people well. Relatives also told us staff provided people with the level of support they needed and knew how to get the best out of 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. People were protected from the risks associated with the spread of infection. We observed the home to be clean, tidy and smelt fresh. Cleaning schedules were completed daily to ensure good hygiene standards were maintained. The provider had an infection, prevention and control policy and procedure. Relatives gave us positive feedback and told us, the home was always clean, tidy and there was no malodour.

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 stored securely and regular temperature checks were completed to ensure medicines remained effective. People received their medicines as prescribed. Medicine records were well maintained, clear, and up to date. Protocols were in place for ‘as required’ (PRN) medicines, providing staff with clear guidance on when these should be administered. This helped to ensure consistency and reduced the risk of inappropriate use. There were effective systems for ordering, receiving, and disposing of medicines safely. Staff received medicine training and their competency were checked to ensure they followed the provider’s medicine policy. The registered manager worked collaboratively with their local pharmacy. Regular audits were undertaken to identify any discrepancies or areas for improvement.