1-2 Canterbury Close

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 66 (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. Accidents and incidents were analysed to identify trends and patterns and to improve the service. Following incidents, debrief sessions were carried out with staff and in team meetings to look at what could have been done differently and what could be improved in the future.

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. Staff and leaders communicated well with external professionals and organisations who provided day activities to ensure consistency of care.

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. Staff received training about how to keep people safe and knew what actions to take if they suspected abuse. One staff member said, “If I ever saw something that needed to be reported I would go to my line manager and if things didn’t get resolved then I would go higher. We have all the contact details available for safeguarding and higher management.”

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. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives. Staff told us they received training to help them understand the Mental Capacity Act. One staff member said, “I have received training on MCA. When applied to my role and put into practice, it requires abiding by the 5 statutory principles, which includes the assumption of capacity to make a decision, unless it can be proved otherwise.”

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. Risks associated with people’s care were identified and managed to keep people safe. Risk assessments clearly documented important information to support people to manage risks safely. Staff knew people well and understood how to manage risks. One staff member said, “The people we support have risk assessmentsin place and these are reviewed on a regular basis, or when there has been a changein the individual's circumstances, in which case they will be updated. The risk assessments are done to ensure the people we support are kept safe and in addition, policies and procedures are in place to make sure staff undertake their duties in a person-centred way, which ensures the individual’s needs are met without affectingtheir safety, dignityand respect.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We carried out a tour of the home with the registered manager and found some environmental safety concerns. Cleaning products had been left out and storage cupboards were unlocked. People’s toiletries and topical creams were easily accessible which created a risk to people, and some large items of furniture were not securely fixed to the walls. Following our inspection the registered manager took appropriate action to address these concerns, including implementation of risk assessments and ensuring more robust checks of the care environment took place.

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's recruitment process was thorough and included relevant pre-employment checks to ensure suitable staff were selected. Staff received an induction when they commenced employment which included mandatory training and shadowing experienced staff. Staff told us training was ongoing and they felt supported by their colleagues and the management team. One staff member said, “Training is an important part of my job and we are encouraged to keep updated on all policies and procedures. We have regular supervisions and yearly appraisals.” Sufficient numbers of staff were available to support people to meet their needs and for them to be involved in activities of their choice.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We carried out a tour of the service and found areas which required cleaning including the kitchen areas in both houses and the laundry. Shower chairs needed a deep clean and the legs on 1 shower chair were rusty. We raised our concerns with the registered manager who took action to replace the shower chairs and improve the cleanliness of the service. However, changes to practice needed to be embedded to ensure cleanliness was maintained.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We looked at the processes in place to manage medicines and found some concerns. For example, 1 person’s medication administration record did not correspond with what medicines were administered. There were occasions where controlled drugs audits had been completed and there was just 1 signature, and some occasions when medicines had been booked in by 1 staff member. We found these were recording errors and no-one had been placed at risk. Following our inspection the registered manager carried out a full stock check of medicines and took action to address anomalies. Staff received additional training and lessons learnt were shared with them. The provider worked within the guidelines of STOMP [Stopping over medication of people with a learning disability and autistic people]. People’s medicines were reviewed regularly to ensure they received the right dose at the right time. Staff received training in the safe administration of medicines and their competencies were assessed. One staff member said, “I have received training in the administration of medication in all its forms as well as the management of ordering, returning, booking in and checking quantities are correct on a daily basis.My competencies are reviewed and checked regularly to ensure my knowledge and understanding of the many aspects of my training are current and appropriate.”