12 Channel Lea

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 72 (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. Where incidents and accidents occurred, through investigations were undertaken and learning was taken to reduce the risk of these happening again. For example, following medication errors there were reflective practice sessions with the staff involved to look at what had caused these, and what additional support could be put in place to address factors that had contributed to them and continually improve practice. There were infrequent incidents at the service, however where they did occur, these were discussed collectively as a team at meetings. These were used to share any learning and changes to peoples care or systems made as a result.

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. There was clear guidance identifying at what point people may need to be referred to wider health care services if staff had concerns about their wellbeing. We saw staff were proactive in doing so, for example one person had struggled sleeping and staff had worked with health services to explore what might be the reason for this. Other people had recent had exacerbations of their health conditions and staff had recognised these and supported them to attend appointments with their GP’s. Staff worked together positively to support people to follow the advice that was given and in continuing to monitor their wellbeing.

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 with the local authority safeguarding team. All staff had completed safeguarding training, and could clearly articulate factors that meant the people they supported might be at higher risk of abuse. They knew the signs to look out for of when they might suspect abuse or neglect was happening and how they would report this to ensure action could be taken to protect people. One staff member explained “We know people’s individual nuances so if their behaviour changes without explanation this would be a cause for concern, or I would also look out for sudden changes in how people are spending their money that might also indicate abuse. I would approach our senior carer or manager to raise my concerns. If I felt nothing was being done, I would follow our whistleblowing policy and contact the local safeguarding team to make a referral.”

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. There were clear and robust risk assessments in place which were regularly reviewed, and set our clear guidance for how staff should safely support people to manage key risks to their wellbeing. Staff had worked with the people they supported for a significant period of time and had a confident knowledge of how to support them. For instance for both people they had seen deterioration in elements of their physical health in recent weeks, and staff had recognised these symptoms and sought emergency or routine clinical advice. This had resulted in changes to people’s care plans being made in line with guidance received, and staff were able to explain how they were continuing to monitor people’s wellbeing in line with their care plan. One relative explained, “They’re managing the risks as much as they can, they’ve very good. They don’t have a lot of turnover with staff either.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. A recent fire inspection had identified some areas where the safety of the building needed to be improved to ensure the spread of a fire could be adequately controlled. This included compartmentation in the roof space and some of the internal fire doors not complying with appropriate fire safety regulations. The provider was aware of these findings and explained the action that would be taken to make the necessary improvements. There were clear plans and timescales of when this would be achieved. In the meantime, there were robust fire safety assessments, evacuation plans and fire drills to reduce these risks. People were able to understand the risks associated with fire, evacuate independently, and there were multiple fire exits available.

However, excepting this, the building was well maintained and there were regular checks on the safety of utilities used such as electricity, gas and water. Where any risks or areas for improvement were identified they were rapidly addressed to ensure people’s safety. Though people and their relatives expressed the environment safely met their current needs, the provider was looking to the future and was in process of looking to install an adapted bathroom to ensure this would be fully accessible to people as they grew older and their needs changed.

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 with all appropriate checks undertaken to ensure they were appropriate individuals to work with vulnerable adults. They had training to ensure they had a confident knowledge in the needs of the people they were supporting, which was checked through regular supervisions and competency checks. There were always sufficient staff to be able to support people in undertaking the things that mattered them, such as in accessing the community. There were systems to regularly review staffing levels were appropriate for the needs of people. Staff themselves told us they were happy there were sufficient staff to safely manage people’s needs and that the hours they worked were safe. One staff member told us, “Yes, we have enough staff. You get the time to rest during the day when you need to. I’ve never had any issues or concerns and happy the hours I work are safe.”

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 was a high standard of cleanliness at the service, with regular checks undertaken by management to ensure this remained the case. Where possible, people were empowered to take ownership of the service and be involved in their own cleaning. We saw from people’s care notes that they regularly supported with cleaning their home with encouragement from staff. There had been a risk assessment of the use of hazardous cleaning chemicals and judged people were aware of the risks and how to use these safely, which was an example of encouraging people to develop important life skills.

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. Medicines were ordered, stored, administered and documented safely by staff who were sufficiently trained and competent to do so. There was clear guidance around how people’s medication should be administered safely, including any side effects staff should be mindful of. The service had processes in place that aligned to the “Stopping over medication of people with a learning disability and autistic people (STOMP)” programme. This is a national initiative aiming to reduce the inappropriate use of antipsychotic medication and focusing on holistic alternatives. For people living at the service who had these medications prescribed there were yearly reviews to ensure they remained appropriate. People regularly chose to spend time with friends and family, and there were safe processes in place to ensure they had the medication they needed wherever they were. Where medication was being given “as and when” for example during pain or exacerbation of a health condition, staff were not recording why medication was being given or if it had been effective. Following our inspection the provider took action to ensure staff were now doing this.