Vesey Road

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 service. This key question has been rated good

This meant people were safe and protected from avoidable harm.

This service scored 66 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

The provider did not have a system to learn lessons from previous experiences to improve the service. For example, incidents and accidents were not reviewed for any trends to prevent similar incidents occurring. The registered manager told us that they reviewed all incidents and accidents and verbally updated staff to ensure changes were implemented, but records were not kept of these discussions. There was a risk of staff not knowing about incidents if they were not present at the verbal handover

However, staff confirmed that incidents and accidents were discussed within team meetings.

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.

A social work professional confirmed this by saying, “This is a good home, the (registered manager) always makes appropriate and timely referrals and seeks help when needed with good communication.” Staff said information was shared with them.

Information was obtained from people, and others involved in their care, about people’s individual needs and risks to their safety. This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care. Most people had lived at the service for a long time. Staff knew people’s care needs and associated risks well. Staff told us they had access to relevant information about people’s care and support needs. Staff monitored people’s changing needs closely and reported changes to senior staff so appropriate referrals could be made to the relevant agencies. There were information risk assessments [hospital passports] in place, to provide hospital staff with important information about the person and the health needs in the event of hospital admission, and some updating of these documents was taking place.

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.

We observed that people were comfortable and at ease with staff. The atmosphere at the service was calm, relaxed, friendly and homely. Staff were attentive and alert to any changes that might indicate people needed support for any anxiety or discomfort they might be experiencing. A relative told us, “[Person’s name] are safe and well cared for. Staff know what to do if they are upset or unhappy about something.” Staff had received appropriate Safeguarding training and were able to tell us how to report any concerns as well as understanding their own responsibilities. The home did not have anyone living there under Deprivation of Liberty Safeguards (DoLS) protection, however registered manager had considered peoples needs during the initial assessment and at reviews with those who had a social worker.

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.

The provider worked with people to understand and manage risks. A family member told us, “[Name of registered manager] always discusses risks with us such as going outside and how they will manage any issues.” People with learning difficulties had care plans reviewed with them and their families in a manner that was inclusive and easily understandable. For example, simple language was used such as, ‘I will try to ask staff before I take any snacks as I may get some food stuck in my throat.’ A risk assessment for a trip to the seaside included comments from families and observations from staff about risks.

The provider did not always detect and control potential risks in the care environment. Although all equipment, facilities and technology supported the delivery of safe care, we found that systems had failed to recognise inherent risks with unlocked doors. We also found that the laundry room had no lock on the door and that chemicals including corrosive materials to be inside the room. The registered manager immediately called a locksmith to place a lock on the laundry room door and instructed staff on ensuring all doors that should be locked are locked immediately. The locksmith attended whilst we were at the home and we saw that the lock was secure. The registered manager was very proactive in making changes where required.

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.

Staff had enough time to provide people with the care and support they needed. Managers made sure people received care and support from the same staff where possible to maintain consistency in people’s care and support and daily routines. Staff were supported with their learning and development needs and encouraged to continually improve in their role. The provider operated safe recruitment practices and only suitable staff were employed to work at the service.

A relative told us, “[Person’s name] is very well looked after, by excellent staff who know their needs well.” A person told us, “The staff are caring, kind and very approachable. They are easy to talk to and want the best for me.”

Staff understood and managed risks. Staff received competency reviews on a regular basis and all training was complete and detailed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The home was clean and tidy with appropriate personal protection equipment used by staff. However, we found that 2 toilet brushes were in an unhygienic state, and this could increase the risk of infection. When we fed back to the registered manager they immediately removed all toilet brushes and implemented a new cleaning regime. Cleaning schedules and audits were in place.

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.

Robust reviews of medicines were made by the registered manager on a weekly basis including checking the Medicines Administration Records [MAR] for accuracy. Staff competency was reviewed in accordance to policy and no errors were found. People were prescribed ‘as needed’ (pro re nata PRN) medication by their doctor. These medications had PRN protocols in place providing dispensing staff with clear instructions on what signs to look for as well as how to monitor any increase/decrease of the use of these medications. The registered manager had a system of rotating stock to ensure that medicines were provided that were in date and regularly reviewed.