Creative Support - Ulverston Autism Service

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 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.

People were protected from the harm related to unsafe events and incidents because the provider had robust procedures in place to fully understand and learn from all occurrences.

The provider’s complex care team closely reviewed all incident reports and provided additional feedback to managers who shared this with staff. Staff were able to apply the lessons learned to support people to feel safe. Information to guide staff and remind them of procedures following incidents was displayed in staff areas. The registered manager promoted a culture of openness in the home.

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.

People’s safety needs had been fully considered when they were supported to access different services including medical appointments and admissions to hospital. The provider ensured everyone had up to date support plans, communication guides and a hospital passport. These included clear details of the persons medical needs and how they preferred to be supported. There was evidence this had enabled some people to access health treatments which they had previously found difficult to tolerate.

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.

People were protected from the risk of harm and abuse. The provider’s policies and procedures were robust. Staff had received safeguarding training which supported them to recognise safeguarding concerns and respond to abuse. Information was displayed in the home for staff and visitors which guided them about how to raise this, if they had a concern. Safeguarding records demonstrated the registered manager, and staff were following the provider’s procedures. The registered manager ensured any safeguarding concerns had been reported to the local authority and CQC when required.

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.

People were supported to be involved in managing risks. The providers’ complex care team and registered manager had supported the staff team to develop and embed a more person-centred and less restrictive approach to risk management.

People’s contribution to decisions about risk management had been enhanced by staffs’ skills and experience; for example, staff were able to understand what was important for people who used non-verbal communication, this helped ensure people's views were represented. Risk assessments and management plans had been reviewed and updated regularly.

People were supported to feel safe and to manage their anxieties and responses. Some people who previously found going outside distressing were now accessing a broad range of activities in the community. The development of person-centred risk management strategies had led to people feeling and being safer.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived in a safe environment. All relevant safety certificates and documentation was in place. All staff had completed health and safety training.

Some improvements were needed in the property. There had been problems with the heating system and some bathrooms needed refurbishment. There were ongoing negotiations with the landlord to address this. The registered manager had offered people the opportunity to use other facilities in the interim.

People were able to access their garden safely because the boundary was secure.

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.

People were supported by enough skilled and appropriately trained staff. The provider had robust recruitment procedures in place. Recruitment records were completed fully, and all necessary pre-employment checks had been completed. Where agency staff had been deployed, the provider endeavoured to use the same agency and ensured they had the profiles for all agency staff. Sponsored staff were employed in line with their visa conditions.

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.

Communal areas were clean and tidy. There were separate housekeeping staff who followed a regular routine. The cleanliness in the bathrooms in some flats needed to improve. There was some mold and malodour, and one bathroom needed new flooring. The provider had been liaising with the landlord and a remedy had been agreed.

Staff and visitors had access to personal protective equipment, (PPE) at various points throughout the home. All staff had been trained in infection prevention and control.

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 any changes happened.

Medicines were managed safely. Policies and procedures were in place which reflected good practice. Staff had received medicines training, and their competencies were checked regularly.

Each person had a detailed medication assessment and support plan. These included person-centred guidance for staff about how to support people to take their medicines.

Protocols for medicines needed only when required were in place to guide staff. These included homely remedies such as pain relief and medicines to support people if they experienced distress. There had been a consistent reduction in the use of these medicines which had improved people’s quality of life because this had meant they were able to engage in more activities.

Medicine administration records had been completed correctly. Medicine audits had been completed regularly. There was evidence that, following a medicine error, staff had received additional training.

The system for the disposal of expired medicines needed to improve, we found out of date medicines for the two people’s medicines we checked. No impact was found, and this was remedied during the inspection.