1 Sheringham Avenue

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 strong and embedded learning culture where staff reflected on practice and used learning to improve outcomes for people. Staff told us incidents, accidents and concerns were consistently recorded, discussed and reviewed, with clear processes in place to identify learning and reduce the risk of reoccurrence. One staff member told us, “Any incident, we discuss it, and we all know how to improve,” which demonstrated a shared understanding of learning and accountability.

Managers reviewed events thoroughly and used findings to inform improvements in practice. Staff described how learning was shared through team discussions, supervision and training, supporting a consistent approach across the service. This ensured staff remained informed, confident and able to respond appropriately to changing needs or risks.

Relatives told us they were kept informed and involved when needed, which supported transparency and trust. The open and reflective culture within the service meant staff felt confident to raise concerns, discuss practice and continuously improve the care provided.

The provider ensured people experienced safe and well-coordinated transitions between services. Records contained detailed and personalised information about people’s needs, preferences and communication requirements, including hospital passports, which supported continuity of care when people accessed external services. This enabled healthcare professionals to understand people and provide appropriate support.

Staff demonstrated a clear understanding of their role in supporting people during transitions. They described how they shared relevant information with external professionals and worked collaboratively to ensure people’s needs were consistently met. For example, staff explained they would support people to attend appointments, encourage them to communicate their needs and provide reassurance where required.

People and relatives told us they were confident in how the service managed healthcare and transitions. One relative said the provider was, “Very good at supporting people with their healthcare needs and keep families involved”, which demonstrated effective communication and coordination.

This approach ensured people experienced safe, seamless transitions, with staff working proactively to maintain continuity of care and positive outcomes.

The provider had effective systems in place to safeguard people from the risk of abuse. Staff received appropriate safeguarding training and demonstrated a clear understanding of how to recognise and respond to concerns. They were able to describe the actions they would take, including reporting internally and escalating to external agencies where necessary, to ensure people were protected.

Staff told us concerns were taken seriously and discussed openly, with managers providing guidance and oversight. Safeguarding processes were embedded into daily practice, and staff understood their responsibilities in keeping people safe. This supported a proactive approach to identifying and reducing potential risks.

Relatives consistently told us they felt people were safe and well supported. One relative described safeguarding within the service as “safeguarding is good. Staff know what to do if they have concerns and are confident to report them”, reflecting their confidence in how risks were managed and how staff supported people appropriately.

This meant people were protected from abuse and avoidable harm within a service that promoted openness, accountability and continuous improvement.

At the time of the assessment, no one using the service was subject to a Deprivation of Liberty Safeguards (DoLS) authorisation.

The provider worked with people and their relatives to understand and manage risks in a way that promoted both safety and independence. Care plans and risk assessments contained detailed, personalised information about people’s needs and potential risks, providing clear guidance for staff on how to deliver safe and supportive care.

Staff demonstrated a good understanding of how to manage risks while maintaining people’s independence. They described how they monitored people’s wellbeing, identified changes and took appropriate action, including updating risk assessments and seeking support from external professionals where required. Staff also completed training to support them in managing risks safely and effectively.

Relatives told us they were involved and kept informed about changes in people’s needs and how risks were managed. One relative explained that staff had, “a good understanding of techniques to use when [person] is in a crisis,” which demonstrated staff had the skills and knowledge to respond appropriately and reduce distress.

We observed staff supporting people in a calm and reassuring manner, using personalised approaches to minimise risk and anxiety. Environmental risks were also well managed. For example, cleaning products and chemicals were stored securely in line with COSHH guidance, reducing the risk of harm to people living in the home.

This meant risks were managed proactively and in a way that respected people’s choices, promoted their independence and supported positive outcomes.

People lived in a safe, well-maintained and personalised environment. The home was clean, tidy and adapted to meet people’s individual needs and preferences. People were able to personalise their bedrooms, which supported their comfort and sense of belonging.

Staff carried out regular checks of the environment and equipment to ensure these remained safe to use. Any issues identified were reported and addressed promptly, demonstrating a proactive approach to maintaining a safe living space. Environmental risk assessments were in place and regularly reviewed to reflect any changes.

People were able to move freely around the home and were not unnecessarily restricted. This supported independence while maintaining safety. The garden area was well maintained and provided a safe and accessible space for people to spend time outdoors.

There were appropriate fire safety arrangements in place. The provider worked with relevant professionals to assess fire safety risks, and staff completed training to ensure they knew how to respond in the event of an emergency. Regular checks of fire safety equipment were completed, and clear procedures were in place to support safe evacuation if required.

This meant people were supported in an environment that was safe, well managed and enabled them to live as independently as possible.

The provider ensured there were enough staff deployed to meet people’s needs and keep them safe. During the assessment, we observed staffing levels were sufficient to meet people’s needs in a timely and responsive way. Staff were visible within the home, available to support people and able to respond promptly without people having to wait. The atmosphere was calm and unhurried, and staff had time to engage with people in a meaningful way, which indicated staffing levels were appropriate.

Feedback from relatives confirmed staffing levels were consistent, and people did not experience delays in receiving care. One relative highlighted the stability of the staff team, describing it as, “a testament that they are able to retain staff,” which supported continuity and strong relationships.

Staff demonstrated they had the skills, knowledge and experience required to support people effectively. They told us they received a range of training relevant to people’s needs, including autism, mental health and the Mental Capacity Act. Staff were able to explain how this training supported them in understanding people and delivering personalised care.

There were robust recruitment processes in place to ensure staff were suitable for their roles. Records confirmed appropriate pre-employment checks had been completed, including identity verification and background checks. Staff completed an induction and ongoing training, with competency assessments carried out to ensure safe practice, including for medicines administration and moving and handling.

Staff told us they felt well supported in their roles and had access to regular supervision and guidance from managers. They described an open and supportive culture where they could discuss their practice and continuously develop. This meant staff were well supported to deliver safe, effective and consistently high-quality care.

The provider had effective systems and procedures in place to prevent and control the risk of infection. The environment was clean, well maintained and hygienic. Cleaning schedules were in place and followed, supporting consistent standards across the home.

Staff demonstrated a good understanding of infection prevention and control practices. They confirmed they had received relevant training and had access to appropriate personal protective equipment (PPE), including gloves and aprons. We observed staff using PPE appropriately to reduce the risk of cross infection.

People and relatives told us they were satisfied with the cleanliness of the home. One person told us staff, “wear gloves when dealing with washing,” which reflected safe and appropriate practice.

This meant infection risks were effectively managed, and people were supported in a clean and safe environment.

The provider ensured medicines were managed safely and in line with best practice. Medicines were stored securely, including in locked storage, and systems were in place to ensure they were administered as prescribed.

People were supported to take their medicines in a way that promoted independence, including being supported to self-administer with appropriate oversight to maintain safety. Staff assessed people’s ability to manage their own medicines and provided support in line with their individual needs and preferences. This included prompting people at the appropriate times, observing administration where required and offering guidance while respecting people’s autonomy. Clear risk assessments and care plans were in place to guide staff on the level of support needed, ensuring a balance between promoting independence and maintaining safety. This approach meant people were encouraged and enabled to take an active role in managing their medicines while risks were effectively managed.

Staff received training in medicines management and completed competency assessments before administering medicines. They demonstrated a clear understanding of their responsibilities, including how to respond to errors or concerns and when to seek medical advice. Staff worked with prescribing professionals to ensure people’s medicines needs were regularly reviewed and met.

The provider followed the principles of STOMP (Stopping over medication of people with a learning disability and autistic people), supporting people to avoid unnecessary medicines where appropriate. This demonstrated a person-centred approach to medicines management, focusing on people’s wellbeing and long-term outcomes.

Records relating to medicines were well maintained. We reviewed medicines administration records (MAR charts) and found these were clear, accurate and consistently completed, with no gaps or omissions. This supported safe monitoring and demonstrated people received their medicines as prescribed.

There were robust systems in place to monitor and improve medicines practice. Managers carried out regular audits and used these to identify areas for improvement and embed learning. Where people required ‘as required’ (PRN) medicines, clear guidance was in place to support staff in administering these safely and appropriately.

This meant people received their medicines in a safe, well-managed and person-centred way, with effective oversight and a focus on continuous improvement.