Walsingham Support - 19 Beech Avenue

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.

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.

People were protected from avoidable harm and safety risks because the provider had effective systems in place to identify, review, and learn from safety events. Robust policies and procedures supported the reporting, investigation, and analysis of incidents, helping to reduce the likelihood of repeat occurrences.

Oversight of quality and safety was enhanced using technology to generate and analyse safety events. The provider shared information and lessons learned across all the locations. This enabled the service to monitor performance, identify emerging concerns, and maintain effective governance arrangements.

The registered manager promoted an open and supportive culture where staff felt able to raise concerns, share ideas, and contribute to service improvement. Regular staff meetings provided opportunities for open discussion, sharing learning, and speaking up about issues affecting people's care and safety.

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.

People were supported to transition safely into and out of the service. The provider had effective assessment and admission processes in place to identify people's needs, preferences, and support requirements before they moved into the home. This helped to ensure the service was able to meet people's needs. People were given opportunities to become familiar with the service at a pace that suited them, including through visits and short stays, supporting a planned and person-centred transition.

People were also supported to move safely between services when required, including during hospital admissions and discharges. Detailed hospital passports were in place for each person and contained up-to-date information about their health and wellbeing needs, preferences, and communication requirements. These documents helped healthcare professionals understand how best to support people and promoted continuity of care during transitions between the home and hospital settings.

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 were protected from abuse and avoidable harm. The provider had clear and robust safeguarding policies and procedures in place, which supported staff to identify, respond to, and report concerns appropriately. The provider demonstrated openness and transparency when safeguarding concerns arose, carrying out investigations and working cooperatively with relevant external professionals and agencies.

Staff had completed safeguarding training and demonstrated a good understanding of their responsibilities in keeping people safe.

People can only be deprived of their liberty to receive care and treatment where there is appropriate legal authority. We assessed whether the service was working in line with the principles of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Although a recent High Court ruling removed the requirement for some disabled people to have a legal authorisation in place for arrangements that may amount to a deprivation of liberty while receiving care and treatment, the provider remained committed to upholding the principles of the MCA. People’s capacity to make specific decisions was appropriately assessed, and where individuals lacked capacity, decisions were made in their best interests and in the least restrictive way possible, taking account of their rights, wishes and preferences.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk management plans were in place to identify and minimise potential risks people faced within their daily lives. These covered areas such as the physical environment of the home, the use of equipment including bed rails, mobility aids, moving and handling needs, skin integrity, nutrition and hydration, and support to access community resources and social activities. The plans provided staff with clear guidance on how to support people safely.

However, some improvements were needed. We saw a person whose behaviour communicated a need was not supported in line with their agreed care plan. Staff had physically intervened to redirect the person contrary to their care plan, which placed them at risk of harm. We discussed this with the registered manager during the inspection, who acknowledged our concerns and responded immediately.

Further improvement in relation to record keeping was needed. One person’s repositioning charts had not been completed consistently by staff. Similarly, records relating to continence care were not always completed. In addition, fluid intake records for one person had not been completed throughout an entire month. This meant there was a risk that people’s needs may not have been fully met and that changes in their health or wellbeing may not have been identified promptly. We did not identify any harm and were assured the registered manager was proactive in supporting staff to improve record keeping.

The registered manager promoted positive risk-taking to ensure people were supported in the least restrictive way possible. As a result, one person was able to experience greater freedom within their own home, enabling them to make more choices about their daily life and increasing their opportunities for social inclusion.

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’s environments were safe, and equipment was well maintained. The provider had effective systems in place to monitor the environment and equipment, identify potential concerns, and respond promptly to maintenance issues. Records demonstrated that required repairs and servicing were completed in a timely manner to help ensure people remained safe.

Fire safety arrangements were robust. Fire safety equipment was serviced and maintained at regular intervals, and staff understood the actions they should take in the event of an emergency. Personal Emergency Evacuation Plans (PEEPs) were in place for each person, providing clear guidance on the support they would require evacuating safely in the event of a fire or other emergency. This helped ensure people could be supported appropriately according to their individual needs.

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.

The provider had robust recruitment procedures in place to ensure staff possessed the appropriate skills, knowledge, and experience to support people safely and effectively. Records confirmed that all required pre-employment checks had been completed before staff commenced employment.

Staff completed a comprehensive induction programme which helped embed the provider's values, culture and expectations regarding the support people should receive. Ongoing learning was promoted through regular access to face-to-face training, enhancing staff knowledge, skills and confidence in their roles.

The provider maintained effective oversight of staff training and development, enabling them to identify and address learning needs in a timely way. Staff received training relevant to their responsibilities, including training tailored to the specific health, care and wellbeing needs of the people they supported.

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 supported to maintain safe infection prevention and control practices. Staff had received appropriate training and demonstrated an understanding of good infection prevention and control measures. Personal protective equipment (PPE) was readily available and used when required. Management oversight helped ensure infection prevention and control practices remained effective and aligned with current guidance.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had clear robust medicine management policies and procedures in place. We found that while most people received their medicines safely, further improvement was needed to ensure this was consistent.

Medicine stocks were checked by staff each day and during monthly audits; however, we found one person had one too many tablets of one medicine, it was not possible to determine when this discrepancy occurred. We found one person’s medicine administration record chart had another person’s name and date of birth on it. Though we were assured the person’s medicines were correct and the name on the chart was an error, this had not been identified by staff. Topical creams did not always have legible labels on them. We raised our concerns during the inspection and were assured by the response of the registered manager.