Better Vision Care

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 newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed safely. 

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were learnt to continually identify and embed good practice. Staff completed incident forms and there were monitoring systems in place, to enable the management team to have oversight. The registered manager understood their duties to be open and honest and reported notifiable incidents to external agencies.

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 had their needs assessed prior to using the service. Staff worked with a range of healthcare professionals, this included district nurses, advocates and social workers. Care records were digital and could be easily shared between services, where necessary. Partners told us they had no concerns about the care people received.

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. Policies and procedures were in place to protect people from the risk of unsafe harm. Staff were trained about how to safeguard vulnerable people. Staff told us they felt comfortable to whistle blow on poor practice, and action would be taken to address any concerns. A person said, “Staff are very kind and caring. If I am upset they [staff] talk to me, we talk about any problems I may have.”

Risks posed to people were mostly assessed and mitigated. Whilst we found no harm to people, we found 1 person's care plan did not contain enough detail about how staff manage their pressure care. This was brought to the attention of the registered manager at the time of our inspection, and this information was added into their care plan. People had risk assessments in place, which contained detail about how staff manage risks posed to people, such as a risk of falls.

The provider detected and controlled potential risks in the environment. People were supported in their own homes. Assessments were undertaken of people's homes, to ensure they were safe and staff understood their responsibilities to keep people's homes clean and tidy. These also included what level of support people required to maintain their homes. People had personal evacuation plans in place, which detailed how staff support people to evacuate in the event of a fire.

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 staff, people and relatives told us they had no missed care calls and records evidenced staff attended calls. We received mixed feedback about staff arriving on time, however where this occurred this was due to unforeseeable circumstances and explanations were given to people. A staff member said, “Staff morale is good, staff are motivated. We allow people to be part of their own care or support by respecting their values, needs, preference and choices.” Staff were recruited safely and received inductions. Staff received training in a range of subjects, to enable them to carry out their roles effectively.

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 had access to personal protective equipment, and the leadership team conducted staff spot checks, to ensure they were adhering to best practice guidelines.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst we found no harm to people, medicines administration records (MAR) charts were not completed accurately or correctly. The service supported 1 person with their medicines and they told us staff administered their medicines. We found several gaps in records, missed signatures for a pain patch and conflicting date entry information. We found a lack of recording where people required differing amounts of medication and there were no protocols in place for 'as required' medicines. There was also a lack of key information on people's MAR's, such as allergies. This meant we were unable to confirm medicines were administered as prescribed.