Endorphins Group

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 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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

We identified ongoing issues with documentation and record keeping. These included delays in completing incident forms and safeguarding documentation not always being completed in a timely way. Managers were aware of the issues and used meetings to share the learning, however improvements were needed to ensure consistent and timely record keeping. Staff told us they met regularly with managers as they completed regular spot checks during visits. Staff told us they had access to team meetings and supervision.

The provider stated that regular team meetings were undertaken. However, meeting minutes were not maintained at the time of assessment, meaning the provider was unable to evidence oversight and information shared with staff.

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. For example, managers provided examples of supporting people to transition between services, including young people moving from children to adult services.

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.

The provider had clear safeguarding systems and processes in place. Safeguarding concerns were recorded in detail and included clear actions, outcomes, and management oversight. Staff appropriately recognised and escalated concerns, and there was evidence of referrals to external agencies, including local authorities, where required.

All staff received appropriate training relevant to their roles. This included essential training in safeguarding children, ensuring they are equipped with the knowledge and skills required to carry out their responsibilities effectively and safely. The provider had safeguarding policies which referred to children and young people.

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. People were involved in managing risks as far as possible, with input from relatives and engagement with the individual. For example, during assessments, staff involved the person alongside their relative, responding to their non-verbal cues such as gestures and vocalisations to confirm preferences. Relatives told us managers always met with them to discuss their relatives care and treatment.

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 provider managed environmental safety through person-centred risk assessments, which identified and mitigated risks specific to each person. Staff were also equipped with mobile phones and digital applications to support communication and maintain their safety while working within the environment.

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.

Staffing levels were generally sufficient to meet the needs of the people, and managers responded to gaps in staffing appropriately. The provider identified, through audits, occasions where staff performance was inconsistent, including issues with timekeeping and adherence to procedures. Managers had taken appropriate action to address these concerns through supervision, support, and escalation where required.

Staff had access to training relevant to their roles. Training included safeguarding, medicines management, and behaviour management. Systems were in place to monitor compliance, and most staff were up to date with required training. Where gaps were identified, managers provided additional support and arranged further training. We saw evidence of coaching and on-the-job learning to improve staff knowledge and confidence.

The provider assessed and managed the risk of infection. They controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff received infection control training. Staff are provided with personal protective equipment (PPE) to support them with the delivery of personal care.

Managers demonstrated a clear understanding of staff competencies and medicines management. Although they were not currently supporting anyone who required medication, provider demonstrated they had the knowledge, systems and competence to support people with medication management, in line with best practice and regulatory standards. The provider had a medicines management policy in place which staff could access.