Tentelow Lane

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 safe. At this assessment the rating has remained as 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, investigated and reported incidents, and used lessons learned to continually improve practice.

Staff were encouraged to learn from incidents and use this learning to prevent similar issues in the future. They followed proper reporting processes, and records were reviewed to spot patterns and improve safety. Care was planned carefully for people who might show distressed or challenging behaviour, with staff avoiding known triggers and preparing for difficult situations. Key information was shared through care plans, meetings, and with healthcare professionals to ensure consistent and safe support. The registered manager held regular meetings to review learning and risks and worked closely with health professionals to keep care responsive to people’s changing needs.

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 provider assessed people’s needs before care began and supported them to access healthcare when needed. People, their relatives, and healthcare professionals were involved in developing care plans to support safe living at the home and in the community. Care plans were regularly reviewed and updated as people’s needs changed. The provider continued to monitor people’s needs to ensure they could be supported safely and worked with other agencies to arrange safe transitions to different services when required.

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 supported in ways that helped keep them safe from abuse. A person told us, “Yes, I feel safe, they do a good a job and look after me and they take me out. They always talk to me nicely and I appreciate it.” Relatives felt confident that their family members were well protected and cared for. Staff knew how to recognise and report any concerns and understood the different types of abuse. They received training in safeguarding to help prevent avoidable harm. The registered manager understood their safeguarding responsibilities and worked with the local authority whenever concerns were raised.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes/hospitals, 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 that staff delivered people’s care in line with the legal requirements of DoLS and principles of MCA. Staff demonstrated an understanding of the MCA and applied its principles in practice. When people’s needs changed, the registered manager submitted DoLS applications to the local authority. At the time of the inspection, 3 people were awaiting authorisation. The provider had arrangements in place to ensure that people’s rights and freedoms were respected.

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 and their relatives were involved in assessing and managing risks, helping to prevent avoidable harm. A relative told us, “Risks, if they feel there is risk staff will always bring it to our attention and tell us what they do to rectify.” Care plans clearly outlined what people could do safely on their own and when staff support was needed, such as with medicines, managing their moods, money, personal care, and meal preparation. Records showed that staff followed guidance and managed risks safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We identified that call bells were not in place within the home. Call bell systems are important to enable people to access timely support and feel safe. We raised this with the registered manager, who acknowledged the potential risks, particularly if people’s needs changed. The registered manager told us a review would be completed and appropriate action taken. In the meantime, measures were in place to mitigate risks, including regular checks to ensure people’s wellbeing.

The building met people’s needs well. People had personalised their rooms with their own furniture, equipment, and décor. Shared areas were comfortable, homely, and well equipped.

The provider adapted the building as people’s needs changed, including a stairlift, a specialist bath, and a sensory room.

People had the right equipment for their needs, and the home was checked to make sure they were safe. Risk assessments looked at possible dangers, such as falls, trip hazards or fire risks. Staff followed safety procedures, used equipment correctly, and took extra care when supporting people during travel or out in the community.

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.

People were supported by enough trained and skilled staff to meet their needs. A relative told us, “I did ask when they get new staff how they train them. I was shown.” There were enough staff to meet people’s needs. Other comments included, “There is a chart on the wall which tells you what staff are on” and “I think staff are pretty competent and on the ball and if they weren’t [Person] will let us know and the registered manager know.” Staff were able to support people properly without rushing.

Regular staff got to know people well, allowing them to provide personalised, high-quality care.

Staff received training and guidance from health professionals which enabled them to support people appropriately. A staff member said, “I learnt via shadowing staff and also doing all the mandatory training.” The registered manager told us, “We work with the local authority and attend training to support staff’s learning and recently attended dementia and end of life (EOL) training.”

Recruitment processes were robust and made sure new staff were suitable for their roles

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.

Staff were trained in infection prevention and control and used good hygiene practices to reduce the risk of infection. They supported people with personal care and helped keep the home clean and comfortable. The registered manager made sure staff had the right personal protective equipment (PPE) and used it properly. They checked this through supervision, spot checks, audits, team meetings, and regular communication.

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.

People were given their medicines safely and as prescribed. A relative told us, “[Person] is on medicines and we have had no issues.” Staff were trained to handle medicines, had their skills and competencies checked, and kept accurate records. The registered manager carried out regular checks. The service worked with GPs to review and change medicines when needed. Up‑to‑date medicines policies were in place to guide staff.

Staff competency to administer medicines was appropriately assessed. People’s medicines were managed in line with Stopping over medication of people with a learning disability and autistic people (STOMP guidance), with psychiatric medications reduced or discontinued where appropriate, ensuring safe and personalised support. As required (PRN) medicine guidelines were in place to support safe administration. Staff followed the protocols for managing PRN medicines.