Excellence Healthcare Services Ltd

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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 81 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff were proactive in learning from incidents that occurred whilst they were providing care and in-between those times to ensure people’s safety and welfare was maintained. There was excellent communication between staff, people and their relatives so everyone was up to date with any accidents or incidents that occurred. We heard examples of staff liaising with relatives about falls that happened during the night when staff were not around. So, staff could check the person for any signs of injury and be aware of any bruising or soreness that they’d need to take account of when supporting with personal care. Staff also noticed that someone was more confused than normal and this prompted them to ask the person questions and they disclosed they had fallen during the night. They were not in any pain, but due to the increased confusion staff arranged for an ambulance to attend to check for any possible further injury.

Incidents and accidents were used as a learning process. A staff member told us, “The registered manager always discusses incidents to teach us how to avoid or deal with them.” Another staff member said, “We also do group meetings online when managers are sharing information about a situation for example if something has happened to another client, they call us to discuss ideas on how to handle a situation.” There was a comprehensive system in place which enabled detailed oversight of any incidents or accidents that occurred, both whilst care was being delivered and outside of these times. They used this system to track whether this indicated any deterioration in a person’s health or whether additional care was required. Staff advocated for people to support with coordination and continuity of care.

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 ensured they received all information available when supporting a person to transition to their service. This included speaking with the referring agency, the person and their relatives. This information was used to inform assessments processed and ensure a smooth transition between services.

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 were knowledgeable of their responsibility to protect people from avoidable harm and to raise concerns if they felt someone’s safety was at risk. A staff member said, “Safeguarding is about making sure everyone feels safe, respected, and cared for.” People felt safe with their care workers. A relative told us, “I feel [my family member] is completely safe.” Any safeguarding concerns identified were quickly reported to the local authority safeguarding team so appropriate action could be taken.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Comprehensive assessments were undertaken to identify any risks to people’s safety. These assessments included information about people’s long term medical conditions, their independence, and their support needs. Staff told us care records gave them clear information about any risks to people’s safety and how to support them. They also understood that risks to people’s safety varied over time and management plans needed to be reviewed and updated regularly. A staff member said, “Yes, care plans and risk assessments give good guidance to help manage risk. They tell me what to watch for, what to avoid, and how to keep my clients safe. But sometimes things can change, so it good to stay alert, follow updates, and ask office or supervisor if not sure.” Another staff member told us, “They (care plans and risk assessments) give us enough knowledge and guidance on how to support our clients and helps us to ensure their safety at all times.”

Relatives felt people were well cared for and staff supported them to stay safe and manage any risks to their safety. A relative said, “Yes, absolutely (I feel safe). It’s a peace of mind and a safety thing to know that someone is coming in.”

Relatives told us the staff were very observant and knew their family members well so could tell if they weren’t their usual self. One relative told us the staff had bought to their attention a change in their family member’s skin and said, “So, we were able to get the treatment that [the person] needed and they were happy to apply the ointment that was needed. They are very attentive. If [the person] is 1 degree under they spot it quickly and express concern. They are really on the ball.”

We saw in people’s care records and through incident records that staff were proactive in identifying if changes to people’s care was required. For example, after a person fell staff liaised with the occupational therapy team to review the suitability of bed rails and, given their mobility needs, there was an agreement that the bed rails increased risks to their safety and welfare and therefore these were removed. Many of the people being supported used pendant alarms, and staff liaised with the alarm call responders if they had concerns relating to a person falling.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental risk assessments were undertaken and staff supported people to maintain a safe environment. Staff were aware of any equipment people were using and checked they were in safe working order.

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.

Safe recruitment practices were in place to ensure suitable staff were employed. Recruitment panels were in place, that often included service user and family representatives, to review applicants suitability and ensure their values were in line with the providers. Staff received a comprehensive induction and regular training to ensure they had the knowledge and skills to undertake their duties. A staff member told us, “I can always ask for extra training if I need help with anything.” Another staff member said, “We also do quizzes that are sent out to us to check our knowledge in the care we are providing.” Relatives told us the care workers were skilled and understood how to care for their family member. A relative told us, “[My family member] has very complex needs and the care workers have all been trained to fully meet his needs physically, emotionally and health wise.” Staff received regular supervision and annual appraisals to review their performance and provide any support they required.

People received care at a time of their choosing. A relative told us, “The care workers are always on time and if I need to change times, the office staff are always happy to be flexible according to what I need.” People received support from care workers who were matched to their needs and preferences. The registered manager said, “We make sure we have the correct care worker with the correct skills to meet the client’s needs…When we do our assessment, we ensure we capture the characteristics of the client. We then make sure we match the care worker.”

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.

Staff had completed training in infection prevention and control (IPC). They understood their duties and the importance of using personal protective equipment (PPE). A staff member said, “I am always provided with PPE like gloves, aprons, and masks.” Audits were undertaken to ensure staff were adhering to IPC policies and procedures. Policies and procedures incorporated national guidelines and the registered manager stayed aware of best practice guidance in this area. An infection prevention and control champion had been nominated within the staff team to lead on this area.

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 received the support they required with their medicines. Staff adhered to safe medicines administration. Systems were in place to monitor staff performance and ensure people received their medicines as prescribed. The registered manager told us, “On the [electronic records] system we can check and track people’s medicine administration charts. This makes it easy to track it. They [staff] cannot log out of the system if they have not given their medicines… The system tracks [medicines] expiry dates and flags if this is coming up.” Regular audits were undertaken to ensure safe medicines management processes were adhered to in line with best practice guidance. Staff received regular training and competency checks to ensure they retained a good understanding of safe medicines management.