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. This is the first assessment of the service. The key question has been rated 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 positive learning culture that promoted openness, continuous improvement and shared learning. The service had systems to record, investigate and review incidents, accidents and complaints, and lessons learned were used to improve practice. Following incidents, debriefs were completed by clinical leads to review care plans and risk assessments, identify learning, and consider alternative approaches to reduce risk. Outcomes included updates to risk management strategies, enhanced staff guidance, additional training, and adjustments to staffing support. These actions helped strengthen people's safety, reduce the likelihood of similar incidents occurring, and support safer, more effective care.

The provider had systems to ensure people received safe care during referrals, admissions, care delivery and transitions between services. Staff completed assessments before care packages commenced to determine whether people’s needs could be safely met. People and their families were involved in recruiting staff to support complex care needs. Care plans provided clear guidance and escalation processes when people's needs changed. A service user guide was also developed, providing key contact information and details on how to raise concerns or complaints. These approaches helped ensure care was tailored to people's needs and contributed to positive experiences and satisfaction with the service.

The service worked collaboratively with health and social care professionals to support continuity of care and ensure people received the right support at the right time. Staff coordinated admissions and discharges to minimise disruption to people and to maintain their safe care arrangements.

The provider had systems and processes to protect people from abuse and avoidable harm. Safeguarding policies reflected current guidance and staff understood their responsibilities for recognising and reporting concerns. Staff told us they knew how to raise concerns and records demonstrated safeguarding matters were investigated and escalated appropriately. One staff member told us “We raise concerns through the system and also by contacting the clinical lead for that care package. We work very closely with them.” Care plans and risk assessments identified potential safeguarding risks and included measures to protect people while supporting their rights and independence.

The registered manager fulfilled their duty of candour by reporting safeguarding concerns to relevant authorities, including CQC. Safeguarding concerns were monitored through governance systems and incident reviews by the registered manager to support oversight and continuous improvement.

People were involved in decisions about how risks to their health, safety and wellbeing were managed. Risk assessments were personalised, detailed and reflected people’s individual circumstances, preferences and goals. Care plans were developed with people and, where appropriate, family members and professionals.

Positive risk-taking was supported where this helped people maintain their independence and quality of life. For example, 1 person was supported to attend a multi-activity residential camp, marking their first overnight stay away from their parents. They participated in activities including swimming, abseiling, zip lining and canoeing. To support their complex clinical needs, including wheelchair use and tracheostomy ventilation, staff completed detailed risk assessments, and appropriate control measures were implemented. This enabled risks for people to be managed safely while promoting independence, confidence and full participation in activities.

Records showed risks were reviewed regularly and updated when people’s needs changed to ensure care remained safe and responsive.

The provider assessed and managed environmental risks to support people to receive safe care in their homes and community settings. Environmental risk assessments considered areas such as access, mobility, fire safety, emergency situations, equipment use and adverse weather conditions. Care plans included clear guidance for staff on responding to emergencies and maintaining safety within people’s homes. The service had equipment registers and servicing arrangements to ensure equipment remained safe and fit for purpose for people. Environmental risks were reviewed by clinical leads alongside people’s care and support needs. One staff member told us, “I always check the environment on each shift for any hazards and report any concerns.”

The provider described how they undertook environmental assessments within people’s homes to identify potential ligature risks and ensure appropriate control measures were implemented in line with individual risk assessments.

The provider had arrangements to ensure enough suitably skilled and competent staff were available to meet people’s needs safely. Staff were not permitted to work independently until they had completed training and demonstrated competence. Training records demonstrated 100% compliance with mandatory training requirements, supported by a system that prevented staff from booking shifts until all required training had been completed. Staffing levels were planned in accordance with commissioned care packages, and specialist training was provided to support staff caring for people with complex health needs.

People and relatives told us staff arrived on time and care was delivered reliably by staff who knew them well. Staffing arrangements were flexible and responsive, helping to ensure continuity of care and minimise missed or delayed visits. One relative told us, “We are very happy with the care team, some nurses we have had since the very beginning, we have built really good relationships with them, we are confident in their care.”

Recruitment processes included appropriate pre-employment checks, such as Disclosure and Barring Service checks, references and verification staff were suitable to support vulnerable people. Most staff received regular supervision, competency assessments and ongoing support to maintain safe practice.

The provider had systems to reduce and prevent the risk of infection. Infection prevention and control (IPC) audits were completed regularly and leaders maintained oversight of compliance. Care plans relating to clinical interventions contained guidance on hygiene, equipment management and recognising signs of infection. Staff received relevant IPC training and competency checks to ensure they could safely undertake their roles. The provider monitored practice through supervision, spot checks and governance processes to support safe standards of infection prevention and control.

The provider had systems to support the safe management of medicines. The service had recently implemented an electronic medicines management system, and all records had been transferred to the new platform.

Medicines administration records, audits and competency assessments were used to promote safe medicines practice and identify areas for improvement. Care plans contained detailed guidance on medicines management, including prescribed medicines, administration requirements and escalation procedures. Staff received training and competency checks before administering medicines and medicines-related risks were assessed and reviewed regularly. Records demonstrated oversight of medicines management and appropriate action when changes in people’s health needs occurred.

However, some staff reported difficulties during the transition onto the electronic medicines management system and identified discrepancies within the system. We shared this feedback with the provider following our assessment, who acknowledged the challenges associated with implementing a new system and advised that these concerns would be reviewed and addressed.