Sheepwalk House

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 recorded and reviewed so any trends or patterns could be identified. The registered manager said, “We discuss safeguarding at team meetings such as lessons learnt unless it is going through investigation. These will be brought up and talked about how we can improve.”

Feedback to staff of any changes to people’s care following an incident were communicated in handovers and staff meetings. This helped to reduce the risk to people’s safety. One relative said, “We know staff, they know us and come into our home. We have a lot of exchange with them and if there are problems, they ask us our opinion and experience.” This meant people benefited from a service that continually improved through reflection and learning.

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 worked with others to solve problems and make improvements. The service communicated with other agencies to help ensure continuity of care. Regular contact was maintained with the local authority, social workers, GPs, and other professionals. Staff said they could reach health professionals when needed. Hospital passports/ grab sheets contained essential information to inform hospital staff how best to support people if they needed to be admitted to hospital. The registered manager said, “If it is an emergency appointment, if possible, we will send 2 staff. A handful of staff would come in if needed or I would go.” A staff member said, “[I’ve] done Oliver McGowan training, really sad but brought into place having that trail of paperwork.” This meant people experienced smooth, safe transitions between services, reducing risk and promoting continuity of care.

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 felt people were safe, knew the manager well and felt able to raise concerns if needed. Staff had completed training in safeguarding; they understood their responsibilities and reported any concerns to management. They were confident any concerns would be dealt with but were aware how to escalate issues outside of the organisation if needed.

The provider had a process in place to report concerns. The management team ensured relevant authorities such as the CQC, and the local authority were informed of incidents or allegations of concern that could affect people’s safety. Staff had confidence any issues reported would be acted on by management.

The provider and staff team had a good understanding of what made people feel safe, and what they needed staff to do to keep them safe. A staff member said, “Safeguarding training we receive is very good and trainers who do the sessions are well equipped to pass on their knowledge.” This meant people experienced care that protected them from risk of avoidable harm, and abuse and protected their right to live safely.

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.

Any risks were identified and recorded with guidance for staff on how to manage risks. When restrictions were necessary to keep people safe, these were proportionate and the least restrictive option. The provider was pro-active in encouraging and supporting staff to follow a positive risk management approach. The registered manager had a good understanding of implementing the least restrictive options for people to ensure people lived better lives.

One person was expressing an emotional response through behaviour which could have put themselves or others at risk. This person previously needed support in the back of the car from 2 staff members for their safety but they now have a cab screen and a seat harness which has made it possible for them to go out safely and more frequently. This meant they were less restricted to being in the home and experiencing less distress behaviours when out. The registered manager told us how this supported the risk management whilst using the least restrictive approach.

Support plans and risk assessments identified potential risks to people’s safety. This included risks such as the support people needed when going to local shops and other amenities, without unnecessarily restricting their freedom. Measures were put in place to support people in the least restrictive way, whilst monitoring the potential risks to the person’s safety as well as the safety of staff and members of the public.

A staff member had worked to create a large list of places they could go to with people and colour coded it as to what would be suitable based on each person’s needs and abilities. The registered manager explained how they had discussed positive risk taking when doing this to optimise opportunities for people, they talked about mini golf as an example and said, “Some staff will question if it is safe for them to have a golf club in their hand. We have also looked at [an outdoor adventure experience]. As long as they follow the rules, like put on the helmet, it’s fine; and if not then stop the activity.” They went on to talk about another activity for another person “[underground boat journey], one staff member said about taking [name]. They had a brilliant time."

This supportive approach enabled people to maintain their autonomy, do the things that mattered to them; while receiving the care they needed to keep them safe and well.

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

We found 3 radiators in the home missing radiator covers. There was one in a shared bathroom, one in a private bathroom and one in a bedroom. The radiators were not in use at the time of the assessment to test how hot these got when switched on, but without a cover, when switched on could pose a risk of scalding. The provider took swift action to ensure these radiators were covered to prevent harm to anyone.

People and staff were involved in fire safety drills, and people had a detailed Personal Emergency Evacuation Plan (PEEP) in place. A night-time evacuation had not yet happened but had been planned in (prior to our visit) to take place a few days after we visited. Innovative ways were explored to assist people to undertake fire safety evacuations, such as using visual fire boards, to assist people to understand and respond.

We noted there was a gap in the recording for the fire checks and health and safety for the previous week. These were new records which had only been newly implemented at the start of August. However, we saw the records prior to that were consistently completed. The registered manager also ensured that any checks and records were completed on the day of our site visit to ensure all checks were up to date. Checks of utilities and equipment were regularly carried out by external contractors. Staff completed weekly and monthly checks such as water temperatures and fire safety equipment.

We saw that the red bags used for emergency fire evacuation had recently been checked and were well stocked with a first aid kit, torches with replacement batteries, foil blankets and PEEP documents relating to each person. We noted some out-of-date information in the fire evacuation plan. The management team ensured this was immediately updated.

We found a cupboard and a tall shelf in the activities room which was not secured to the wall. We were informed that a person living at the service liked to rearrange the furniture in the room and it was a way of them regulating their emotions. The activities room was locked when nobody was using it to help keep people safe and a member of staff was always with people when the room was in use. Whilst this had been dynamically risk assessed it had not been recorded on paper. The manager took action to complete a risk assessment on the day of the site visit.

Adaptations had been made to the environment to support people’s safety. For example, there were wooden boards fixed across the spindles in the stair banisters and painted to be in keeping with the rest of the staircase, to prevent people from being able to remove the spindles and protect everyone’s safety.

Prior to our visit the provider had done an audit of the property and created a plan to make improvements. The floor in the downstairs hallway was in need of repair, and this had already been ordered prior to our visit to be fixed. Any similar issues were pointed out by management to the inspection team demonstrating openness and transparency in the assessment process. We saw a plan for a new kitchen which had been ordered complete with new appliances. The management team took swift action to address any issues we found meaning people were kept safe from harm.

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 their own staff on a 1:1 or 2:1 basis each day, this enabled people to choose what they liked to do each day. New staff were recruited safely and completed an induction before starting work. There were sufficient staff to meet people’s needs and enable them to take part in any pastimes or hobbies they enjoyed. When asked about induction, a staff member said, “One of the best I had, loved the training, I got more out of it, everyone is friendly and helpful, people have been so supportive. This is my place.”

The provider had safe recruitment practices to help ensure suitable staff were employed. All necessary pre-employment checks were completed before staff began working in the home. Staff received regular supervision, and the registered manager was planning yearly appraisals. Staff completed regular training, to make sure they had the knowledge and skills to carry out their duties. A training matrix showed staff had completed training in relevant areas including supporting people with a learning disability and autistic people. The management team monitored the training matrix to make sure staff remained up to date. The registered manager said, “We offer NVQ diploma level 2 or 3 offered after probation. Consensus say that they have to have completed all their training first. They [staff] are encouraged to bring forward ideas for training. Consensus do a whole learning academy for staff.”

Staff confirmed they received regular support and supervision, and all spoke highly about the quality of the training and support they received. A staff member said, “We learnt every course we could go on, and we get plenty of training and refresher, safety intervention, the actual trainers make the courses interesting as well.”

There had been a change in staff and though relatives felt like this was well managed they commented that there had been some inconsistency at times as a result. One relative said, “I do think as with all care homes they get turnover of staff, they have a continuous core staff. They have permanent night staff been there a long time.”

Relatives felt this staff turnover was well communicated and understood. A relative said, “We are always ready to help out on very odd occasions. [Registered manager] is good at juggling things; all service users get what they need and get out and about. This meant people received care from staff who were skilled, available, and able to meet their needs safely.

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 were trained in relation to infection, prevention, and control. We observed most staff wearing Personal Protective Equipment appropriately. There was a staff member wearing blue gloves whilst completing daily tasks where these would not be required. This was raised with the management team in relation to the potential for cross contamination who quickly acted to address this with the member of staff.

Relatives told us the home was clean. One relative said, “Yes always clean, got a cleaner who is lovely, we say to them, they should be one of the carers. There are always workmen there doing bits and bobs and keeping it tidy.” Another said, “Really clean they’re always cleaning, when I use the loo it’s always spotless.”

Systems were in place to promote safe Infection, Prevention and Control (IPC) practices, such as cleaning schedules and auditing. People had their own bedrooms, however only one person had their own bathroom. Staff did each person’s laundry separately which helped to prevent people's clothes getting mixed up or misplaced. Each person’s clean or dirty clothes were placed in named colour coded laundry baskets before or after washing. This would help prevent any cross contamination.

We found some edges of flooring was not sealed and apron holders in bathrooms were starting to rust. We were told by the provider that there was already a plan to change the apron holders and that action would be taken to seal the floors. People were receiving the right support from staff with maintaining their personal hygiene and the home was kept clean and well maintained when any issues arose. This meant people were protected from infection and disease.

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.

Each person had individualised medicine support plans and risk assessments. These informed staff of each person’s needs. This included the times they needed to take their medicines, the dosage and possible side effects.

The service had a generic flammable risk assessment in place for people who were prescribed paraffin-based skin products. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN,” was available to staff. Administering medicines as directed by the prescriber reduces the risk of people experiencing adverse effects from the medicine. We checked the quantities and stocks of medicines and found stock balances to be correct. This meant that we could be assured that the correct doses of medicines had been administered as signed for by staff.

The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. There were no controlled drugs on site at the time of our inspection. However, there were appropriate arrangements in place to enable the safe management of these if necessary. Records were completed to indicate the name and quantity of medicines taken on off-site visits.

There was a process in place to record medicines related incidents or errors. Records showed that staff had received medicines handling training. The registered manager told us staff had safety intervention training where they discussed PRN medicines in relation to restrictive practices to help with stopping over medication of people with a learning disability and autistic people (STOMP). Staff competencies were assessed regularly to make sure they had the necessary skills to safely support people with their medicines. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed. This meant people received their medicines safely and effectively, supporting their health and wellbeing.