Real Life Options - 90 Capel Gardens

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 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 positive culture of safety, based on openness and honesty. However, staff did not always investigate and report safety events appropriately. Lessons were not always learnt to continually identify and embed good practice.

A system was in place to report, record and monitor incidents and to help support people safely. Accident/incident forms recorded the action taken following an accident/incident but there was a lack of detail around the injury sustained and lessons learnt. We raised this with management who said that they would amend the form to include this and in future this would be documented.

Management discussed accidents/incidents with staff during meetings to help ensure staff were familiar with their responsibilities and what action to take in such an event. However, we were made aware that a recent incident had not been reported appropriately. We discussed this with the manager who confirmed staff would receive refresher training to help ensure they took appropriate action in future.

Records showed that the leadership team reviewed accidents and incident data to help identify trends and themes.

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.

Communication and hospital passports were used to help support safe transitions between services. These contained key information about people’s needs and routines to support continuity of care. Staff supported people to attend appointments and hospital admissions to promote safety and reassurance. Relatives told us they were kept informed of people’s progress and changes to their care needs.

People and their relatives were involved in the assessment process so that their views and wishes were taken into account when planning their care and support.

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.

Procedures were in place to help safeguard people from abuse and improper treatment. Staff were able to recognise signs and symptoms of abuse and received training to help ensure they were up to date with best practice guidance. Staff said they would report concerns and wouldn’t hesitate to do so.

When asked if they felt safe in the home, a person said, “Yes.” Relatives told us they were confident their family members were safe in the home and in the presence of care staff. A relative said, “They keep [person] safe.” Another relative told us, “I do believe my [family member] is safe.”

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’s care plans contained detailed risk assessments and guidance for staff on how to manage risks associated with people’s care and support.

Systems were in place to help ensure risks people might face were routinely assessed, monitored and reviewed. These included, for example, personal care, health conditions, accessing the community and taking part in activities. People’s care records contained detailed information for staff to follow. This helped ensure risks people might face were mitigated, so people remained safe when taking part in daily life activities.

The manager and staff were aware of the potential risks people might face and the steps they needed to take to help reduce or safely manage them.

The provider identified and controlled potential risks in the care environment. They helped to ensure equipment, facilities and technology supported the delivery of safe care. The provider assessed the home for risks and took action to help ensure people, staff and visitors remained safe.

Relatives told us staff maintained a safe environment. We observed that the home was clean, free from odours and trip hazards, and that environmental safety measures, such as window restrictors, were in place. Fire risk assessments had been completed, and fire drills were carried out regularly. Staff had completed fire safety training. Regular environmental and health and safety checks were completed, with any identified actions addressed. Records confirmed that gas, electrical, portable appliance and legionella testing were up to date. People were supported to personalise their rooms in line with their preferences, helping them feel comfortable and safe within their own environment.

People had individual Personal Emergency Evacuation Plans (PEEPs) and fire drills were completed regularly. There were clear fire evacuation plans and staff demonstrated understanding of the action they would take in the event of a fire.

The provider made sure there were enough qualified, skilled and experienced staff. Systems were in place to help ensure staff received training suitable for their role and that they have the required qualifications.

Records showed that staff had received training in areas relevant to their roles. The majority of staff had not received supervision sessions in 2026. There was therefore a lack of evidence to demonstrate staff had had an opportunity to discuss their role, performance and development. We raised this with management who acknowledged this and provided evidence to confirm that they were in the process of carrying out supervisions and would ensure these were carried out consistently.

Policies and procedures were in place to help recruit staff safely. Checks on the suitability of potential staff were completed. This included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and help prevent unsuitable people from working in care services.

Staffing levels were sufficient to safely meet people’s needs, and rotas were planned to ensure continuity and consistency of care. The majority of staff told us there were sufficient staffing levels. Our observations found staff were prompt and responsive when providing care and support to people in communal areas.

The provider assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and were aware of the procedures to follow if any concerns had to be shared.

Staff followed infection control processes, including washing their hands, keeping people’s home’s clean and wearing personal protective equipment (PPE) where appropriate.

Relatives we spoke with told us the home was clean and raised no concerns. A relative said, “The home is always clean and is in good condition generally. It is spick and span.”

Staff had completed training about infection prevention and control. Staff said they had enough PPE.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines management systems were in place.

Medicine Administration Records (MARs) were completed by staff. We looked at a sample of these and found these were mostly completed fully indicating medicines were administered as prescribed.

Staff received training to administer medicines to help ensure they had the appropriate knowledge and skills.

Medicines were stored appropriately.

Where people were prescribed medicines on a when required basis (PRN), there were protocols in place to advise staff on what circumstances and how to give these medicines. We however noted that the reasons for administering PRN were not always clearly and consistently documented. We raised this with management who acknowledged this and said they would review their systems and ensure staff received further training in respect of this.

The manager carried out weekly and monthly medicines audits to monitor medicines administration. We reviewed a sample of these and found that audits did not always identify issues with the completion of MARs. We raised this with management and they advised they would review this.