National Star College - Ullenwood

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 outstanding. At this assessment the rating has changed to 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.

The provider promoted a positive learning culture where concerns, incidents and feedback were discussed openly, and lessons learned were used to improve practice and reduce the likelihood of reoccurrence. To embed learning, the national lead of quality and safeguarding completed an annual report to review concerns, complaints and compliments for the preceding 12 months. The data from this report was used to generate themes and trends and proactively identify and manage any risks.

Learning was routinely discussed through multi-disciplinary team (MDT) reviews, staff meetings and debriefs. This provided opportunities to reflect on incidents, identify learning and implement improvements. Risks were addressed and used as opportunities to learn and reduce the likelihood of recurrence.

The head of risk and compliance prepared and presented a report to board 3 times per year. This report provided a detailed analysis of incidents, accidents and reportable events including themes and trends over a 12-month period. This process had recently been developed to improve oversight and accuracy of the reporting process, and allowed systems to be reviewed and improvements made on an ongoing basis.

Relatives generally spoke positively about the learning culture within the service. One relative said, “I'm an extreme worrier, but it wasn't long before we were able to hand over and have confidence in them.” Another relative said, “Everything you bring up is dealt with.”

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 provider operated strong systems to support people through transitions and changes in care. They worked with people and those close to them to establish comprehensive individual transition plans, mitigating risks and ensuring the person received continuity of care. We observed a multidisciplinary review meeting process which ensured people and their families were fully involved when planning future support. Staff worked collaboratively to develop clear transition plans, ensuring people remained at the centre of decision-making. Relatives told us they felt supported throughout transition processes and described positive experiences of planning for future accommodation and support. We spoke with the transition support team manager who described the comprehensive support people and their families receive during their time at National Star College and beyond. This included ongoing monitoring of people’s transitional progress, annual families and carers forums, and other events.

We heard how the provider was committed to ongoing learning to support continuous improvement and development. The provider completed destination analysis on each student who left the college and reviewed their position 1 and 3 years after leaving college. The provider told us they were expanding this further to gather feedback 5 years post college to capture people’s experience and drive meaningful improvement on an ongoing basis.

People experienced a smooth process when they were referred to a different service. Information was shared so people received the care and support they needed, in line with their individual plans. We saw how the provider had engaged in a pilot scheme to develop collaborative work with a charity to develop an ongoing, integrated transition pathway, bridging the gap between specialist education and community life. We also saw feedback shared form another local provider who said, “The quality of information sharing and transition planning undertaken by the team at National Star has enabled us to understand each person's strengths, preferences and support needs before they move, creating smoother transitions and reducing anxiety for individuals and their families.”

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 and their relatives told us they felt safe living at the service. One relative said, “[My family member] is elated when [they go] back, that’s how I know [they feel] safe.”

Safeguarding concerns were tracked and reviewed, and lessons were learned on an ongoing basis. These concerns triggered care plan reviews, safeguarding referrals, liaison with professionals and updated risk assessments. This demonstrated the service was alert to risks of abuse or neglect and acted when concerns emerged.

The provider had up-to-date safeguarding policies and procedures in place for identifying and reporting abuse. These had been recently reviewed following a lessons learned exercise in response to a safeguarding incident. The provider undertook a robust review process, identified key learning, and implemented improvements to mitigate the risk of a similar occurrence and enhance safeguarding practice in the future.

Easy read safeguarding information was available, which supported people to recognise unsafe care, abuse, and routes for raising concerns. Easy read information refers to accessible text presented in a simplified format using clear language and supportive imagery.

Staff received regular adult and child safeguarding training and demonstrated strong awareness of how to recognise and respond to concerns. People were assured if they ever raised a worry, staff would take prompt action to keep them safe. The safeguarding lead told us, “It has to be a collective culture where everyone understands their safeguarding responsibility.”

Staff told us they felt confident in recognising and responding to safeguarding concerns. They described how their regular training had strengthened their understanding of the different types of abuse people could be exposed to, and how this informed their everyday practice. Staff were clear about the actions they would take if they witnessed or were told about any concerns. They also expressed confidence in the registered manager and the individual management team, telling us they trusted them to act promptly on any issues raised. The chief executive told us, “Keeping safeguarding alive in people's lives is where [our safeguarding lead] is focussing [their] energies and doing that as creatively as possible. When you are working with as many staff as we do now, we ensure they work within the National Star culture of dignity, respect and transparency.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had applied to the local authority for DoLS authorisations where appropriate. The provider had a record of all DoLS applications made, including details of any conditions to the authorisations.

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.

When people communicated their needs, emotions or distress, people were consistently supported in a positive way that protected their rights and dignity. People’s care plans reflected any foreseeable risks that might need restrictions, ensuring measures were always the least restrictive option possible. The provider employed positive behaviour support practitioners focuses to work specifically with people who were expressing distress. Evidence-based interventions and strategies were used to minimise the need for restrictive interventions. De-briefing took place, and the service maximised learning for the future about the causes of people’s distress. We spoke with a residential manager who told us how the provider had consistently adjusted staffing support for a person who was experiencing a difficult time. They implemented weekly multi-disciplinary meetings and were highly responsive to the person’s needs. The residential manager said, “If you don’t get it right then it could detrimentally affect care. [When people demonstrate behaviours of communication] they have really positive outcomes. Support is built around individuals.”

There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. People were encouraged to take carefully managed risks in order to live fulfilling lives. For example, before joining the college, one person had been significantly impacted and limited as a result of their epilepsy and complex healthcare needs. We heard how joined up working, engagement with healthcare professionals and a strong commitment to supporting the person in line with their preferences had improved their life. A residential manager said, “Having feedback from staff and [the person] and staff is imperative…we have robust risk assessments. We are responsive to feedback. In [the persons] previous provision [they] didn’t access a lot of what [they do now]. For example, [they] wouldn't be able to swim if [they] had 2 seizures a day. Now we have the provision to take positive risks and [they are] going in the pool will help. We use dynamic risk assessments.”

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 environment was well-maintained by a well-equipped site services team. People lived in residencies designed and adapted to meet their needs. The signage, decoration and other adaptations to the premises helped to meet people’s needs and keep them safe. Environmental risk assessments had been completed on an ongoing basis to identify hazards and put measures in place to minimise identified risks.

The provider undertook a range of checks of the physical environment to help ensure they were safe for people. These included inspections and testing by suitably qualified contractors relating to fire safety, gas safety, electrical systems and water hygiene. The provider also completed regular health and safety assessments to help maintain a safe environment. Where recommendations had been made by external agencies, such as the fire service, the provider demonstrated a commitment to working collaboratively to address these in a timely manner.
The service had a ticketing maintenance system so all work could be managed, prioritised and appropriately addressed.

We visited during a heatwave and reviewed systems and processes in place to ensure safety of staff and people. The provider intended to manage the risk on an ongoing basis with further air conditioning and shaded outdoor space across the site.

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 were recruited safely to the service. This included requesting and receiving references from previous employers, right-to-work documentation and Disclosure and Barring Service (DBS) checks. DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people at the time.

The service took into consideration people’s needs and preferences when staff were recruited, and what personal and professional qualities staff could bring to their work. Staff received a comprehensive onboarding and induction which gave them the skills and knowledge to deliver support in line with the providers expected standards of care.

We observed there were enough staff to meet people’s needs and staff were knowledgeable about people’s needs. Staffing levels were reviewed on a routine and ongoing basis to ensure changing needs were responded to promptly. We saw examples of how staffing needs had been adjusted at short notice to respond to their changing need, health and preferences.
Staff received regular opportunities to share and gather feedback at team meetings and individual supervision sessions. These included key themes which were covered on a rotational basis so staff remained skilled and up to date with internal policies and best practice guidance. The provider acted efficiently when they identified areas for improvement. For example, the management team monitored feedback and themes and determined that more support was needed for staff during night shifts. As a result, a night deputy manager role was developed and implemented across the Ullenwood site. This change led to increased staff support and guidance and improved outcomes for people.

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 were clear roles, responsibilities and procedures around infection prevention and control that met current and relevant national guidance. Staff were trained and understood their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises and their own personal hygiene, including hand hygiene. Staff demonstrated a good understanding of infection control and prevention procedures.

Residences were clean, tidy and free from odour. We observed staff used and had access to supplies of personal protective equipment to help prevent and control the spread of infection.

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 stored securely. There was an adequate stock of prescribed medicines. However, there were gaps in the daily temperature monitoring records for medicine’s storage rooms and refrigerators.

Medicines were administered as prescribed. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both). The records we reviewed provided assurance medicines were not being used to control people’s behaviour. The staff worked closely with local health agencies and the GP practice to support people with their medicines and health needs. Medicines were regularly reviewed by the GP from the local GP practice.

Person centred care plans were in place to support people with their health needs such as diabetes and epilepsy. Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation, pain and anxiety. Guidance in care plans and protocols was in place for these medicines to be administered consistently.

There was a medicine policy and a process to report and investigate medicine errors and incidents. Staff carried out medicine management audits to identify gaps and make improvements. The staff received training and were competency assessed to handle medicine safely.