4 Hermitage 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 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.

Leaders had oversight of accidents and incidents and ensured any lessons learnt were distributed to staff. This was in the format of staff meetings and shared documents. Staff told us they felt this was an effective process. Leaders also shared learning across other services within the company to further promote a learning culture.

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 had ‘emergency packs’ in place ready to take with them in the event of a person being admitted to hospital. These contained key information about people’s needs.

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 told us they felt safe and we observed staff supporting people safely. Staff had received training in safeguarding and told us they did not have any safeguarding concerns. Where safeguarding incidents were identified, these were escalated accordingly to the local authority and reported to CQC. People had Deprivation of Liberty Safeguards (DoLS) in place or applied for where appropriate. These area set of legal protections designed to prevent the unlawful deprivation of a person’s liberty.

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 incorporated into their care plans. These contained key information to help staff understand how to manage risks. We observed staff managing risks safely and supporting people to take positive risks. For example, 1 person was supported to help prepare some lunch and make some salad. Relatives felt staff managed people’s risks well.

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

All required health and safety certificates were in place for electrics, gas and water safety. Health and safety audits took place regularly and there were no health and safety concerns identified during the inspection. Staff took part in regular fire drills and had received training in fire safety.

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.

Staff had been recruited safely and had completed a range of training relevant to people’s needs. This included specialist training in supporting people with a learning disability. Staff commended the training they had received. Comments included, “The training is really good here, the Makaton [sign language aimed for people with learning disabilities] training is fantastic” and “The training is comprehensive”.

Staff felt there were enough staff to enable people to do things they wanted to do.

Staff told us they received regular supervision and leaders maintained oversight of ensuring these were completed. One staff member commented, “This is one of the places I’ve worked where [supervisions] are so frequent.”

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 service was clean and well maintained. There were cleaning schedules in place to ensure the service was cleaned regularly and thoroughly. Staff undertook audits in relation to infection prevention control to maintain compliance. Relatives commented, “The home is really clean, super clean” and “The environment is always clean, it’s very nice when I’ve been there.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People received their medicines as prescribed. Any risks relating to medicines had been identified and risk assessments were in place, for example for prescribed creams which had flammable properties.

People had clear protocols in place for ‘when required’ medicines, such as pain relief. Staff received training in medicines and had their competency assessed regularly. Staff worked in line with the ‘Stopping the over medicating of people with a learning disability’ initiative, by ensuring people had regular reviews of their medicines.