Greenfields 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.

Good: This meant people were safe and protected from avoidable harm.

This service scored 69 (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.
The provider maintained clear records of accidents and incidents. We saw the registered manager regularly reviewed these to identify any themes or trends. Where areas of concern or examples of good practice were identified, these were shared with the wider staff team to support learning. Staff we spoke with identified an example, “Following a fall, a person was diagnosed with a fracture in hospital. We completed all the required reporting, followed medical advice, and made sure they were cared for and monitored during their recovery. We kept clear records and communicated well, which helped us reflect and learn. This included improving how we assess risk, share information, and adapt support to help reduce the chance of it happening again.”
This approach demonstrated a culture of continuous learning and improvement. It helped to strengthen practice and ensured people were supported in a way that promoted their ongoing safety and wellbeing.
 

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 registered manager completed thorough assessments for people referred to the service. These were carried out in partnership with the person, their relatives, current care provider and relevant professionals. This collaborative approach ensured the service was able to meet the person’s needs effectively. The manager also carefully considered compatibility with people already living at the service, which helped to ensure people could live together safely and reduce the risk of conflict.
People had detailed communication and hospital passports in place. These supported a smooth transition if a person needed to attend hospital and provided healthcare professionals with clear information about their clinical needs, communication methods and personal preferences.
For example, one person’s communication passport clearly outlined their communication needs and preferences, which included how they expressed themselves and what helped them feel comfortable. This supported hospital staff to understand them better and provide consistent, person-centred care during their visit.
People were actively involved in planning any moves between services, alongside their relatives and professionals. This helped ensure transitions were well planned, person-centred and carried out in a way that minimised anxiety and supported positive outcomes.
 

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.

The provider worked in line with the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework to support people who may lack the capacity to make specific decisions for themselves and promotes people being supported to make their own decisions wherever possible. Where people were unable to do so, decisions were made in their best interests and in the least restrictive way.

Mental capacity assessments were completed consistently and reflected people’s current needs. We saw the registered manager responded appropriately where needs had changed, for example by updating a person’s care plan in relation to covert medicines to ensure decisions remained lawful, clearly recorded and in the person’s best interests.

Where people required restrictions to keep them safe, the provider ensured appropriate applications for Deprivation of Liberty Safeguards (DoLS) were made to the relevant local authority. This helped to ensure people’s liberty was only restricted when necessary and legally authorised.

Staff had access to safeguarding and MCA policies and demonstrated a good understanding of their responsibilities. This supported them to protect people while also respecting their rights. A staff member gave an example of protecting a person’s rights by supporting them to make their own choices about daily routines. The person was given information in a way they could understand and was supported to express their wishes. As a result, their choices were respected, promoted independence, dignity and person-centred care.

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 were supported to take part in activities that were important to them, including attending day services and going on a variety of outings. These were appropriately risk assessed to ensure people could participate safely. For individuals with limited verbal communication, care plans clearly detailed their preferred communication methods. This helped staff to provide information in a way people could understand and supported them to make informed choices.
We saw examples of positive outcomes for people. For example, one person living with diabetes received consistent and effective support. This included regular blood glucose monitoring, support with diet and medication, and guidance to manage their condition safely. As a result, their blood sugar levels had improved and were more stable, which reduced the risk of complications.
Risks to people’s health and wellbeing were clearly assessed, with appropriate measures in place to minimise harm. This supported people to remain safe, promoted their independence and enabled them to do the things they enjoyed.

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.

Staff demonstrated an awareness of safety within the environment and generally took action to reduce risks. However, we identified some areas where further improvements were needed. For example, we observed wardrobes that had not been secured to the wall, which could pose a risk of tipping. We also noted a fire door that did not close effectively, which reduced its ability to contain fire and smoke in the event of an emergency. In addition, some rugs were not secured, which created a potential trip hazard for people.

These issues were raised with the registered manager, who responded promptly and took action to address them. This demonstrated that whilst systems were in place to identify and respond to environmental risks, they were not always reliable.

Overall, there were monitoring systems in place to check the safety of the environment. Where concerns were identified, action was taken to minimise risks and help keep people safe.

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.

We reviewed documentation which showed staff received regular supervision to support their performance and development, which staff also confirmed. Staff completed a structured induction and had opportunities to shadow experienced colleagues, helping them to build confidence and competence in their roles. Training was provided to ensure staff had the appropriate skills and knowledge to support people safely and effectively.

Staff completed relevant training for their role, which meant people were supported by staff who had the skills needed to meet their individual needs and help them work towards their aspirations and fulfil their potential.

Staff told us they felt well supported and were encouraged to develop their skills and knowledge.

One family member said, “Staff are very well trained, they know my loved one very well and can tell if they are not happy. They will do something to reduce the issue, so it does not get worse. In fact, they are amazing, if my loved one becomes very agitated, the staff just take it in their stride and get on with whatever needs doing”. Another said, “I have never had an issue with there not being enough staff. I find they all seem to know what they need to do and how to do it”.

The provider followed safe recruitment practices and had a supporting policy in place to ensure staff recruited were suitable to the role. The registered manager had ensured they had recruited enough staff and did not use external agency staff to support with continuity for people. The combination of processes and staff training and support ensured appropriate staff were employed to support people safely.

The provider had not consistently assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We identified the environment was not always maintained to a hygienic standard. For example, light pull cords did not have appropriate coverings and areas of flooring were damaged, which meant surfaces could not be effectively cleaned. In bathrooms, sealant around showers and baths was worn and discoloured, which reduced the ability to maintain cleanliness.

We found some furniture and furnishings, including chairs and rugs, were stained and not effectively cleaned, which increased the risk of potential infection. Food items were not always stored appropriately to ensure they were safe for use.

The registered manager took prompt action to address the issues identified and immediate measures were implemented to reduce risk, such as ordering food storage boxes and removing or securing rugs.

All outstanding issues were resolved by the day following the assessment, which ensured concerns were addressed quickly and effectively.

The provider had an up-to-date infection, prevention and control policy to guide staff practice. Staff had access to personal protective equipment (PPE) and were observed using this in line with infection, prevention and control (IPC) guidance. Staff supported people with their personal hygiene needs, and we observed people wearing clean clothes.

Overall, some improvements were required to ensure infection, prevention and control practices were consistently followed and that the environment was maintained to a standard that effectively protected people from harm.

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.

Medicines were managed safely, and systems were in place to support effective medicines optimisation. People received their medicines as prescribed, and staff followed clear processes for administering, recording and monitoring medicines.

Person-centred information was available to guide staff, including the use of photo identification to ensure the correct person received their medicines. Care plans included clear guidance on how each person preferred to take their medicines, such as with food or drink, or using specific techniques to support those who may require additional reassurance or support. This helped to ensure medicines were given safely and in a way that respected people’s preferences.

Staff were trained and assessed as competent to administer medicines and followed best practice guidance. Records were accurate, and regular audits were carried out to identify any issues and support continuous improvement.

Overall, people were supported to receive their medicines safely, in a way that was personalised to their needs and preferences, promoting positive health outcomes.