An Darach House

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 registered manager promoted a positive learning culture where staff were encouraged to be open and honest when things went wrong. Incidents and accidents were reviewed to understand what had happened and identify where improvements were needed. Staff were supported to reflect on events and discuss learning to help reduce the risk of similar incidents happening again.

The registered manager used information received to identify themes and make improvements to the service. Learning was shared with staff and incorporated into action plans. Staff told us they felt able to raise concerns and discuss issues openly. The registered manager investigated safety events and took action where needed.

The registered manager considered people's needs when planning transitions and worked with relevant professionals to support continuity of care. The registered manager completed assessments before people moved into the service and shared information about their needs and preferences with staff to help ensure consistent care and support. People and their relatives spoke positively about their experiences of moving between services. A relative told us, “[Staff] did an excellent transition with day visits and overnight trips.”

The registered manager had effective safeguarding systems in place to help protect people from abuse, neglect and avoidable harm. Staff understood their responsibilities and knew how to recognise and report safeguarding concerns. Incidents were reported appropriately and action was taken when needed. The registered manager was proactive in identifying any gaps in staff knowledge or practice relating to safety and safeguarding and acted promptly to address concerns.

Relatives told us they felt their family members were safe living at the service. A relative told us, “[My family member] is safe here. There were some low-level incidents and staff informed me immediately. No accidents or falls here. The staff know them very well and they have the same staff to look after them.” Another relative said, “Only one incident in the past. They know [my family member] very well. Staff let me know straight away if anything is wrong.” Another relative said, “Very safe compared to the previous place. The people here are caring, and [my family member] has had no injuries. The place is not noisy or boisterous and people are calm.”

The registered manager supported people's right to make decisions about their care while promoting their safety. Mental Capacity Act assessments and best interest decision making processes were in place where needed. Conditions attached to authorised Deprivation of Liberty Safeguards (DoLS) were being met. Relatives told us they were involved in reviews relating to restrictions placed on their family members where appropriate. We observed people moving freely around their home and receiving support from staff when they wished to leave the service.

People’s relatives and representatives were aware of changes which are due to come into effect from 2 October 2026. The ruling may improve people's access to legal protections by ensuring restrictions placed on them are appropriately assessed, authorised and regularly reviewed. Subsequently, people’s mental capacity to make decisions about restrictions in place was being reviewed to see if and how this new ruling impacted them.

The registered manager involved people in managing risks and supported them to live as independently as possible. Risks were assessed and managed in a way that balanced people's safety with their rights, choices and preferences.

People were encouraged to take calculated risks and do the things that mattered to them. Staff understood people's individual risks and provided support that reflected their needs. People were able to access the local community, holidays, day trips, sports and the service grounds with support where needed to help maintain their safety and independence.

Risk assessments were regularly reviewed and provided guidance for staff on how to support people safely. The registered manager took a least restrictive approach to risk management and considered how people could maintain choice and control over their lives while reducing the risk of harm.

People lived in a safe, well maintained and personalised environment that met their needs. The registered manager identified and managed environmental risks and ensured equipment was safe to use.

Relatives spoke positively about the environment and the opportunities available to their family members. One relative said, “There was a new kitchen fitted 6 months ago. Outside there is a fishpond in the garden that is fenced off with a gate. The fish all have names. [My family member] loves to sit in the swing seat outside. Lovely garden which is secure and private.” Another relative told us, "The garden is pristine, the place is clean, new furniture and is well cared for.”

People had access to spacious indoor and outdoor areas which supported their wellbeing and independence. The service had extensive garden space and a separate games room which people could use for relaxation and recreation. People were encouraged to contribute to maintaining the cleanliness of their home where appropriate.

The registered manager ensured equipment was regularly checked and serviced and took action when concerns were identified. Fire safety risks were managed and Personal Emergency Evacuation Plans (PEEPs) were in place to support people in an emergency. Accessible information was available throughout the service, including easy read and pictorial formats, to help people understand information and make choices about their daily lives.

The registered manager ensured there were enough staff with the skills and experience to meet people's needs safely. Staff worked well together and understood the needs of the people they supported.

Staff knew people well and had developed positive relationships with them. This helped staff provide care that reflected people's needs and preferences. Staff received extensive training, supervision and support to carry out their roles effectively. New staff completed an induction to help them develop the knowledge and skills required for their role which included shadowing more experienced staff members.

The provider had effective recruitment procedures in place to help ensure staff were suitable to work at the service. Staffing arrangements enabled people to receive support when they needed it and helped promote their safety and wellbeing.

The registered manager had effective systems in place to reduce the risk of infection and maintain a clean environment. Staff understood their responsibilities for infection prevention and control and had access to appropriate personal protective equipment when needed.

Relatives told us the home was clean and tidy and did not raise any concerns about infection risks. The service was clean, well maintained and suitable for the people living there.

The registered manager completed regular checks to monitor infection prevention and control practices and took action when required. Suitable supplies of personal protective equipment such as disposable gloves, aprons and hand sanitiser were available to staff to help prevent the spread of infection.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff demonstrated a good understanding of people’s medicines and provided person-centred support. They administered medicines on time, maintained accurate stock records and used effective systems to manage medicines when people left the home to go on holiday or stay with family on visits. Staff completed their required medicines training and competency assessments. There were effective medicines storage arrangements in place. Care plans, risk assessments and PRN (when required medicines) guidance supported staff to provide safe and individualised care. The service had governance systems in place to monitor medicines management, including audits, stock checks and processes to identify and escalate concerns before they affected people.

We identified some medicines documentation concerns. For example, one PRN protocol had not been fully completed, some medicines records did not fully align with prescribing instructions, and changes to variable dose medicines had not always been escalated appropriately. We also found one electronic medicines administration record (eMAR) contained an incorrect medicine selection. Although the incorrect medicine had not been administered, the record did not accurately reflect the prescribing information and required correction. These issues increased the risk that medicines may not have been administered, recorded or monitored as intended. Staff were aware of these concerns and had taken steps to improve oversight of medicines records.

Some medicine labels had become faded or rubbed off, reducing assurance that staff could consistently check medicines against prescribing records. Although care plans generally contained sufficient clinical information, some records required updating to ensure medicines-related information was accurate and consistent across the service. The registered manager took prompt action during the inspection to address the issues identified.

The registered manager had an awareness of STOMP (Stopping Over Medication of People with a Learning Disability, Autism or both), and people's medicines were regularly reviewed to help ensure they remained appropriate to their needs.