Thornbury Community Services

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to 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.

There had been no serious incidents in the 12 months before this inspection.All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff met to discuss that feedback. There was evidence that changes had been made as a result of feedback. Staff were debriefed and received support after a serious incident.
 

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.
Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate.
Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.
Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
 

We reviewed 6 care records including the risk assessments and found that staff had reflected the patients voice well.
There were 710 incidents of restraint in the 6 months before this inspection, none were in the prone position but 150 were in the supine position. The supine position is where the person is laying on their back, facing upward.
Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.
 

Staff carried out risk assessments of people’ homes to ensure they identified and mitigated any potential risks. This included potential ligature risks, risk to staff lone working and general health and safety.
The service ensured suitable equipment was in place to help them safely care for people. Staff regularly cleaned equipment after people used it and labelled equipment to show when it was last cleaned. We saw this on our visits to clients’ homes. Staff carried out daily safety checks of specialist equipment.
Staff disposed of clinical waste safely. Clear operating procedures were in place to ensure all clinical waste was managed safely.
 

Managers had calculated the number and grade of nurses and healthcare assistants required. This was based on the commissioned packages that the service took on.
There were enough staff to carry out physical interventions (for example, observations and restraint) safely (and staff had been trained to do so).
There was adequate medical cover day and night with on call clinicians available to staff.
Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.
 

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Staff adhered to infection control principles, including handwashing.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Staff adhered to infection control principles, including handwashing.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Staff adhered to infection control principles, including handwashing.

Staff spoke enthusiastically about their roles in relation to medicines. Staff engaged clients in decisions about their care and were aware of the principles of Stopping Over Medication of People (STOMP) and Supporting Treatment and Appropriate Medication in Paediatrics(STAMP). Staff supported clients to receive annual medicines reviews and health checks.
Records were kept in the person’s home whilst active and then returned to base to be uploaded onto the electronic record system once completed. We saw that in some cases records were not accurate and not all prescribed medicines were accurately listed on Medicines Administration Records (MAR).
There was an inconsistent approach to documentation of medicines prescribed to be use “when required” or PRN. In some cases, the details were documented in specific PRN protocols and in other cases this was documented in the client’s care plan.
Processes were in place for reporting and learning from medicines errors and near misses. Learning around themes identified through these reports was shared with the team.
However, monthly medicines audits were not always taking place and therefore the issues we saw with medicines had not been recognised and rectified. Staff told us that their workload was too large and they did not have time to undertake these audits.

Staff spoke enthusiastically about their roles in relation to medicines. Staff engaged clients in decisions about their care and were aware of the principles of Stopping Over Medication of People (STOMP) and Supporting Treatment and Appropriate Medication in Paediatrics(STAMP). Staff supported clients to receive annual medicines reviews and health checks.
Records were kept in the person’s home whilst active and then returned to base to be uploaded onto the electronic record system once completed. We saw that in some cases records were not accurate and not all prescribed medicines were accurately listed on Medicines Administration Records (MAR).
There was an inconsistent approach to documentation of medicines prescribed to be use “when required” or PRN. In some cases, the details were documented in specific PRN protocols and in other cases this was documented in the client’s care plan.
Processes were in place for reporting and learning from medicines errors and near misses. Learning around themes identified through these reports was shared with the team.
However, monthly medicines audits were not always taking place and therefore the issues we saw with medicines had not been recognised and rectified. Staff told us that their workload was too large and they did not have time to undertake these audits.