Consensus Support Services Limited - Moor Lane

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 75 (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 reported and recorded. Actions were taken to mitigate future risks. Patterns of behaviour were monitored and explored. Adjustments were made to people’s care to support reducing incidents. Staff were aware and vigilant of people’s safety and raised any concerns with senior staff. Lessons were learnt from safety events to ensure changes needed were made. These were shared with the staff team through meetings and handover. A staff member said, “We discuss in staff meetings any lessons learnt."

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 service conducted pre assessments to ensure the home could meet people’s needs. People were supported to visit and transition to the home. Several relatives told us the service supported a positive transition for their family member after challenges in other services, “They made a difficult thing easy. They were noticeably more professional” and “Moor Lane were brilliant when [Name of person] moved, they took their time and they settled in.” The dynamics of people living together were considered as most placements were planned as long term. The service had supported 1 person to successfully transition to live in a separate area of the service, where they had more space and greater independence.

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. Relatives said, “[Name of person] is safe” and “[Name of person] is always happy to go back, always a good sign.”

Staff received training in safeguarding adults. Safeguarding concerns were reported to the local authority and Care Quality Commission (CQC) as required. We highlighted where reports of unknown injury or marks would benefit from further details to ensure potential causes were explored and documented. Deprivation of Liberty Safeguards (DoLS) were applied for and managed appropriately. The registered manager kept an overview of the current status of people’s DoLS. Information was recorded in people’s care plans around people’s current DoLS status to ensure staff were fully aware of this status.

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. Individual risks were assessed. For example, around people’s health conditions, mobility and accessing the community. Guidance was specific for how staff should positively support people in areas of their care. This included photographs and visual guidance to direct staff in the correct positioning for people in bed and for use in their equipment. Risk assessments were regularly reviewed and adjusted when risks had changed. The service supported people with a positive approach to risk. Staff assessed activities and opportunities for risk whilst enabling people to try new experiences. For example, measures were put in place so 2 people could safely enjoy a hot tub experience on their holiday.

An on-call system was available to support staff out of office hours. Staff told us managers were always available. People had personal emergency evacuation plans to direct staff how to support them in an emergency situation. When an unforeseen event had occurred at the service in 2025 people were supported afterwards with a debrief and the actions taken communicated.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks on the environment and equipment were conducted to ensure they were safe for the intended use. This included both internal and external assessments in areas such as fire, water, electrical and moving and handling equipment. Recommendations from the most recent fire assessment had been completed or work had been scheduled. A business continuity plan was available to guide staff in unforeseen circumstances such as a utility failure or extreme weather. An action plan was used to identify and progress environmental improvement work over the short and longer term.

People were able to access safe outdoor space, which contained seating and a sensory garden. Staff told us how the garden was utilised in warmer months for activities, relaxation and social interactions. People’s rooms had been personalised in design and arranged to meet both physical and sensory needs. People’s rooms were regularly checked and maintained.

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. Recruitment procedures were followed including police, right to work and reference checks. New staff received a structured induction programme which included introduction to the organisation and the individual service. Staff told us the induction was comprehensive and enabled them to get to know people and become orientated to the home and local systems. Staff told us they were supported well through this process from their colleagues, senior staff and managers. A staff member said, “The 2 week induction, sets the expectation in terms of quality [of care].”

Staff received regular 1 to 1 supervision with a senior staff member. Staff told us they were well supported and managers were always available. The service ensured staff supervision was monitored through the registered manager overview. Staff completed a range of training. This included mandatory training including fire safety and first aid, training specific to individual’s needs, such as epilepsy and percutaneous endoscopic gastrostomy(PEG) training. Training was also completed around the service user group, including recognised training in learning disabilities and autism. Training focused on person centred and positive behaviour approaches. Staff were supported to develop their knowledge and skills and progress within the organisation.

We received positive feedback about staffing levels at the service. Relatives said, “There are enough staff,” and “Plenty of staff there.” A staff member told us, “Staff levels are really good.” Staffing allocations were managed to ensure people received their commissioned levels of staffing. People received support from a consistent team who knew them well. There had been positive improvements made in staffing arrangements with no agency staff being used and a full and consistent team of staff. A health professional said, “There has been a good level of staffing.” Rotas reviewed demonstrated staffing levels deemed safe by the provider had been adhered with and people received the one-to-one support they were allocated.

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 received training in infection, prevention and control (IPC). Staff had access to personal protective equipment (PPE) and individual use was described in people’s care plans. This was observed being used as appropriate. Cleaning schedules monitored areas attended. We highlighted where some additional information on IPC documentation would be beneficial in giving fuller details and where separate laundry baskets would aid reducing cross contamination risks. These were actioned after the first day of the assessment.

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’s medicines were managed and administered safely. A relative said, “Medicines are well managed.” People’s preferences for how they liked to take their medicines were described. Temperatures of storage areas, including refrigerated medicines were monitored to ensure medicines were managed as directed. Medicines that required additional storage were kept in line with legal requirements. Protocols for as required (PRN) medicines detailed when people may need additional medicines. These clearly described how people would communicate or indicate specific pain or discomfort. People’s medicines were regularly reviewed in line with the principles of Stopping Over Medication of People with learning disabilities, autism or both (STOMP).

Staff received training in medicines administration and had their competencies routinely assessed. People’s medication and topical administration records were completed to indicate when medicines and creams had been administered. We highlighted where the documentation of the running balance of medicines was not following the provider’s guidance and best practice. This was adjusted immediately. Regular medicine audits were completed. Daily checks completed enabled prompt identification should an error occur. Fuller details of whose medicines had been reviewed during monthly audits was highlighted and the provider said this would be actioned.