Yorkshire and Humber Healthcare Alliance (West)

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 inspection for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The provider reflected on an incident whereby staff responses to a person’s changing needs could have been more proactive. Their investigation was not sufficiently robust in its findings and therefore an opportunity was missed to share wider learning (although significant harm resulted). The registered manager reflected on this and provided assurances about their ability to reflect on previous incidents.

There were other instances where the registered manager and others had clearly implemented learning from incidents.

Policies and procedures were regularly reviewed in light of national safety alerts and good practice.

People felt safe and their relatives described a peace of mind using the service. One relative said, “They are wonderfully caring and committed to service user safety.” Another said, “We have no concerns about safety.”

The registered manager worked well with other stakeholders to help people have continuity of care and support, for instance when accessing other parts of the healthcare system.

Pre-assessments and ongoing reviews of people’s needs meant staff had a good understanding of people’s needs and families could be reassured about the care and support people received.

The provider worked well with local agencies to ensure people had safety systems to call for help when they were on their own.

Policies, procedures and communication with people meant they had a clear understanding of what to expect from the service.

People and relatives did not have any concerns about their safety. People knew they could raise concerns if they had any, and were confident in the ability and openness of leaders to respond.

The registered manager ensured safeguarding policies were up to date. Training and supervision ensured staff were suitably equipped to spot and escalate safeguarding concerns. One external professional told us, “We haven’t received any negative feedback from individuals who receive care, or from our social work colleagues or health partners.” Another external professional said, “I have confidence because they have flagged issues in the past.”

Risk assessments did not always give enough person-centred detailed information about the specific risks people faced, and how staff should help reduce those risks. However, some risk assessments needed review to improve the level of detail they provided to staff, particularly in relation to skin integrity and falls risks. The registered manager was responsive to our feedback in this area.

People and their relatives were involved in how their care plan was set up and reviewed, meaning details about how to reduce risks benefitted from their input. This ranged from details around exactly how to leave people’s houses if they were at particular risk of falls, to what warning signs to look out for when people had a specific medical condition.

The registered manager used the electronic records system well to monitor risk and update care plans.

People and relatives confirmed staff were knowledgeable and respectful of their space at home, and helped keep their environment safe. This meant staff tidied after themselves, knew how and where people wanted things leaving, and were mindful of clutter and other risks. The provider considered risks like smoking and put in place appropriate measures. One relative said, “The carers come on time and stay until all their task are completed, leaving things neat and tidy and clean and when they go – you can’t ask for more than that.”

People had confidence in the ability of staff to keep them safe. They confirmed they regularly saw the same staff. The provider understood the importance of people receiving a continuity of care and tried to minimise staff turnover. One person said, “The carers do all they can to arrive near the time slot and stay for the full amount of time on the care plan.” The provider had an electronic call monitoring system in place to ensure staff supported people in a timely fashion.

The provider completed appropriate recruitment checks for new staff and there was shadowing and competence checks to ensure staff were able to support people safely.

People and their relatives confirmed staff used Personal Protective Equipment (PPE) when needed. They had observed them maintain good hand hygiene practices and maintain people’s homes in a respectful way. One person said, “They always dispose of things properly – gloves and the like.”

Staff received Infection Prevention and Control training as part of their induction.

The provider had policies and procedures in place to reduce the risk of people and staff catching and spreading infections.

People’s medicines were managed safely. One person said, “I always get my medication on time.” Another said, “I manage that myself but they always remind me.” The provider’s use of an electronic medicines administration system meant they were able to minimise errors and monitor medicines management at any time. Staff had received training in how to administer medicines. Medication competency checks and unannounced spot checks on practice meant the registered manager assured themselves of staff competence in administering medicines.

The provider’s policies regarding medicines were up to date and in line with good practice.