23 Cecil Road

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 78 (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 encouraged and supported to raise safety concerns with the provider. Relatives told us they were informed if there were any incidents, but most confirmed there had never been any concerns raised.

Leaders told us they had a system in place to learn when things went wrong. Records confirmed incidents and accidents were logged and reviewed for any themes and trends, and any learning was shared with staff. Staff understood the actions to take when incidents happened and confirmed they understood the importance of reporting safety concerns and had information about any subsequent learning shared with them.

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 had a system in place to support people to transition into and out of the service. The registered manager described how people’s transitions were individualised to them to ensure a safe transition. People were listened to by staff when their initial care plans were being created. The registered manager also ran a supported living project, which people could choose to move on to, when ready for this type of support. This helped ensure people were supported to receive continuity of care.

Staff told us they had enough information to be able to support people safely when they came into the service. Where needed, other professionals were involved in peoples care and the advice given was included in peoples care plans and staff followed this.

The provider had standardised policies and procedures in place to ensure the way they supported people reflected best practice in terms of safe and effective ways of working.

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.

Leaders had a system in place to log any incidents and report them to the appropriate bodies. There were effective measures in place to safeguard people from abuse. We saw information had been shared to all staff following incidents, to increase awareness of the relevant policies and procedures.

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. The provider had a system in place to make applications for DoLS for people, and these were monitored to ensure new applications were made as needed. Care plans reflected the information and staff understood this.

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 lived safely and free from unwarranted restrictions. People were supported to take positive risks, which increased their quality of life or helped with their independence. This ranged from cooking, to going on holidays. This was because the service assessed, monitored and managed safety well, taking into consideration people's equality and diverse needs.

People’s individual risks were regularly assessed and details in care plans included how to support their care and health needs, families were involved in this process where appropriate.

Staff knew the people they supported well and were aware of the symptoms and cues which might indicate they were becoming unwell or distressed. Staff told us they understood how to support people to manage any risks to their safety. One explained, “Staff work tirelessly to enable people we support to live fulfilling lives, allowing positive risk taking, to enable growth and confidence”. 

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 were supported by staff who had access to technology which enabled quick access to care documentation, guidance and records. This ensured staff had access to the most up to date information to support people. Detailed autism and sensory assessments and care plans were in place where appropriate. These helped to ensure people were cared for in an environment that met their sensory needs.

Routine safety checks were completed which meant people were living in a safe environment. Equipment checks and audits were completed consistently, helping the provider detect issues early and take action to prevent harm.

Staff confirmed that sometimes people they supported with sensory overload could benefit greatly from noise reduction in their environment. People were therefore supported to access several different areas of the home, which had proven effective in reducing behaviours that challenge and reducing individual anxieties, demonstrating how simple adjustments had made a big difference to individual lives.​

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Recruitment processes involved people being included in the interviewing stages when they wished, which meant they had genuine influence over their support. One person had really enjoyed being involved in the process and asked completely different questions to those they had initially planned, this demonstrated how people were empowered to take more control of who supported them. New staff completed a comprehensive and structured induction programme, which included knowledge checks, direct observations and competency assessments. They undertook shadowing and a trial period before working independently, ensuring they were fully prepared for their roles and confident in the provider’s expectations around safe practice. One person shared with us how they had a new staff member currently supporting them, who they knew as had been supporting another person in the house previously. They explained it was nice to have someone different to speak with and they were coming up with new and different ideas of what they could do together.

Staff had time to get to know people exceptionally well, which meant they could interpret their needs well and provide highly skilled and prompt support. Staff confirmed they had sufficient training to provide a good knowledge and understanding of supporting people with autism effectively. Mandatory training included approved training in supporting people with a learning disability and autistic people. One staff member shared, “The training provided is comprehensive and directly tailored to the unique needs of the people we support”. Senior care worker roles had been developed to strengthen oversight and continuity. Several staff commented on the opportunities and the continuous training available, which had enabled them to develop both personally and professionally.

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.

The provider had effective systems in place to assess, monitor, and manage the risk of infection. Staff were proactive in identifying potential infection risks and took timely action to prevent the spread of infection. Leaders carried out regular spot checks to ensure staff demonstrated consistently safe and compliant infection prevention and control (IPC) practices. Staff had access to appropriate personal protective equipment (PPE) and followed practices such as safe hand hygiene and adherence to policies to support good hygiene standards.

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 had person-centered medicine plans which ensured that medicines were managed safely and they received their medicines as prescribed. Medicine records were personalised, clearly detailing how each person wished to be supported, any known allergies, or specific methods of preparation or administration. People’s medicines were regularly reviewed by prescribers.

People were kept motivated and engaged in meaningful activities they enjoyed. Leaders confirmed this helped in reducing behaviours that communicated distress and prevented individuals from getting over-anxious or requiring medicine to keep calm. National best practice guidance was followed including the principles of STOMP (stopping over-medication of people with a learning disability, autism, or both).

Medication administration records (MAR) were completed accurately and showed people received their medicines at the right times. Staff confirmed they had completed medicines training and passed competency assessments. Medicines were stored securely, and appropriate audits were in place. Clear guidance was in place to support the safe administration of PRN (as required) medicines.