Voyage (DCA) Doncaster

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 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 78 (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 recorded, reviewed and analysed. There was a culture of reflective practice for staff following accidents and incidents. This created a positive learning culture which identified lessons learned and continuous improvements to the service.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. The provider carried out pre-placement assessments along with transition planning and transition visits for people moving into the service. This ensured the transition into the service was successful. The provider used compatibility assessments to determine people’s sensitivities to and from other people already living in the service. The compatibility assessments identified how potential risks could be reduced and mitigated. The management team had put an approval checklist in place which ensured all appropriate pre-assessment and placement checks had been completed. The provider focussed on making sure placements were successful for everyone who lived in the service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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 management team alerted the local safeguarding adults team about concerns raised about the service or people. There was an appropriate safeguarding policy in place and members of staff had accessed training which ensured they knew how to make alerts to keep people safe. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place, through the Court of Protection, to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met. A member of staff confirmed they felt confident to report any concerns about safety, “We have access to safeguarding policies and there are also posters on the walls around the building with information on how to report safeguarding concerns. [If I had any concerns] I would report to my manager, or ‘on-call’ if I could not speak with my manager, to report a safeguarding concern. I would ensure the person is safe and away from anyone/anything causing harm. I would make sure everything is documented and give reassurance to the person. I would report any abuse to the police also.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. Risks associated with people’s care and support were assessed and risks mitigated appropriately. People’s care plans and risk assessments were detailed and contained a positive focus on people developing independent living skills and being supporting to live the life they wanted to live. We saw evidence people were supported to take positive risks to support their journey to independence.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider liaised with the landlord and environment checklists and risk assessments were completed before people moved into their flats within the service. The outcomes of the risk assessment made recommendations about improvements to the environment and any potential challenges which needed to be managed before people moved into the service. The external environment and people’s accommodation was managed by a landlord independent of the provider. Our observation of environment did not identify any specific risks or concerns which impacted on the provision of care and support for people.

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 which met people’s individual needs. People had dedicated teams of members of staff who were deployed effectively to meet their assessed needs. Members of staff were recruited safely and had access to training and support from the provider. Pre-employment checks, including Disclosure and Barring Service (DBS) checks, were completed before new employees started work. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. A member of staff told us, “We complete mandatory training via various methods. Some are e-learning, some are online classrooms via teams and some are classroom- face-to-face. Members of staff also read care plans and support guidelines which are person specific. I have regular supervisions and yearly appraisal meetings. I feel very supported by the new registered manager. They listen to what I have to say whether it be personal issues or concerns regarding work.”

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. There was an infection prevention and control (IPC) policy in place and there were personalised protocols in place which detailed how members of staff should provide personal care safely. Members of staff attended IPC training courses and they confirmed they had access to personal protective equipment (PPE). A family member told us, “[Person’s] home is lovely and clean. The fridge is always full. The bathroom is spotless. [Person’s] bed is always made. [Person] helps to wash up the pots and pans and tries to dry them. [Person] gets support to put washing in the machine then help to hang it out. They are encouraged to help to cook too.”

The provider made sure 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. Medicine administration record (MAR) charts were completed by members of staff and checked and audited by the registered manager. Detailed protocols were in place for people’s ‘as and when’ medicines. Where people received their medications covertly, the appropriate best interest decision making processes had been followed. The provider used a reflective practice approach, combined with additional training and support, to identify learning following medicine administration errors. A family member told us, “[There have not been any] medication errors. [Members of staff] look into [person’s] medicines to make sure they are on the right doses.”