Exmoor Drive

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 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. For example, staff received additional training where it had been identified the current training provided was not sufficient in the areas of bowel management and palliative care. Medicine audits had highlighted there was a theme of medication errors relating to transcribing errors. As a result of this, all senior staff were retrained and transcribing competencies were completed. In addition, a specific area was designated for staff to complete these tasks to reduce the risk of interruptions and errors occurring. People and their relatives told us they felt safe and any concerns in the home were listened to and acted on. People knew who they could speak with if they felt unsafe. One relative said, “I think [person’s name] is as safe as they can be.” Another relative said, “If any issues, they (staff) always get in touch, and we find a way forward.”

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. Care records showed people were supported to access services they may need such as referrals to speech and language therapists and community learning disability nurses. One healthcare professional said, “Referrals have been made in a timely manner when advised by professionals in our service.” Staff contacted professionals such as GPs if people needed support. Processes were in place to share important information about people. For example, people’s hospital passports were taken with them should they need to go to hospital. A hospital passport ensures healthcare staff understand how best to support the person, including communication methods, likes, dislikes and daily routines.

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. Staff had safeguarding training and knew how to recognise and respond to signs of abuse. One staff member talked about the council safeguarding policies and safeguarding board and went on to say, “Any concerns I would go to my line manager, then to the registered manager. Could escalate as far as CQC.” Relatives spoken with did not raise any concerns about safety or the care their loved ones received. One relative said, “I have no worries. Makes me pleased to know [person’s name] is in good hands.” Another relative told us, “Safety fine. Care, no concerns.” Where people were being deprived of their liberty, referrals had been made to the local authority. The manager monitored people’s Deprivation of Liberty Safeguards (DoLS) referrals, and any conditions attached to a person’s authorised DoLS.

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. Risks posed to people were assessed and mitigated. These included risks relating to the environment, mobility and eating and drinking. Staff were trained to deal with incidents of distress. Staff knew people well and understood how to support people’s anxieties. They knew the signs to look out for and how best to manage these. For example, the compatibility of some of the people living at the home was not working therefore, to prevent people becoming distressed in their living situation a decision was made, in a person’s best interest, to move them to one of the other units within the home. Care records contained detailed information about possible triggers and guidance on how staff should react. Following these guidelines can reduce anxiety and distress for people, leading to a calmer, more comfortable environment which people reacted positively to.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental checks were carried out to ensure a safe, hygienic and secure environment for people. One relative explained how their loved one’s bedroom layout had changed to give them more space around the bed. The provider had plans in place to ensure continual improvements to the home environment were made, including updating the kitchen area in 1 unit, replacing all windows and decorating all rooms. The kitchen in another unit had recently been updated. A relative said, “The atmosphere is more homely than institutional, than other places we have been to.” Personal emergency evacuation plans were in place for people which included information about the person, specific details of disability/mobility issues, disability aids, ability to react to warnings, assistance the person may need to evacuate the building in an emergency and agreed evacuation procedures. Trial runs of evacuation with people had been carried out. One person told us, “Staff tell me when the alarm is to go off, so I wear my ear buds because I don’t like the noise, but if it’s a real alarm, I go out of the door.” Another person said, “I go to the car park.” A further person physically showed us the fire door and said, “I’d go across the road (car park) where the fence is.”

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. We received mixed feedback regarding staff levels. Most staff spoken with said there were enough staff to support people whereas, some other staff felt more staff would be beneficial. One staff member said, “Wish more staff to be able to do more activities, plan day trips and spend more quality time with people.” A family member told us, “They could always do with more; it would be nice to have more. We tried to get continuing healthcare (CHC) funding as [person’s name] was in bed a lot and needed one to one care, [person’s name] still would (get the one to one) but couldn’t get funding for it.” Another relative said about staffing, “There always seem to be plenty.” The home used relief staff to cover staffing shortfalls. The management team shared some shifts were being covered by agency staff due to long term sickness absence and vacancies within the team. The management team were open about current vacancies and explained other factors being a reason there was a current hold on recruitment. Staff received relevant training to enable them to carry out their roles effectively and safely. This included training in areas such as communication and the care certificate. The care certificate is an agreed set of standards that defines the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme. Staff working at the home through the council or agency were also provided with training which included an induction, fire guidance, eating and drinking training and competency. There were some gaps identified on the training matrix which had been identified through audits. Plans were in place to ensure staff completed any outstanding training in a timely manner. Staff received supervisions. Senior staff hold supervisions with support staff, and team leaders carry out senior staff members supervisions. Supervision meetings include discussion on personal development and health wellbeing support. Meeting minutes contain actions, names of people responsible to complete the actions and date to complete. Systems were in place to ensure staff were recruited safely. This included checking their identity, their eligibility to work in the UK, obtaining at least 2 references and Disclosure and Barring Service (DBS) checks. The DBS checks helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Some information and documents were held onsite whilst others were in the possession of the recruitment department at the County Council. Where this was the case a confirmation of checks and clearance was provided to the registered manager by the council and held on site.

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. The home looked clean. There were some areas which needed cosmetic improvement, for example, some doorframes and radiator covers were chipped. The provider had plans in place to address this. Staff had received training in infection prevention and control. This meant they had the knowledge and skills of working hygienically and using personal protective equipment (PPE) to keep people and themselves safe. Staff confirmed they had access to sufficient PPE. People and their family members did not raise any concerns with us in relation to the home being clean and tidy. People told us staff encourage them to keep their home clean and tidy. One person said, “I clean my room myself.” A relative explained how their family member liked things left as they wished where they wanted and staff respected this. They said, “Their bedroom is not very tidy, but they have freedom. The general areas are tidy.” In addition to staff maintaining a clean, safe, and hygienic environment staff told us an external company attend daily to help manage infection control and maintain standards.

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. Professionals had shared concerns with us about staff understanding of bowel management and record keeping. For example, recognising the signs and symptoms of constipation and the importance of monitoring bowel movements to identify constipation and knowing when to administer ‘as and when’ (PRN) medication. However, they told us, “Recently I feel this has improved and the people living in Exmoor Drive are able to have their needs met.” There were clear body maps in place for topical creams to show the site of application, however, there were no ‘date of opening’ on topical creams. In addition, we identified there was no body map in place for a person who was prescribed transdermal patches. We provided this feedback to the senior member of staff and management team who assured us they would rectify this. There were clear and detailed protocols in place for ‘as and when’ (PRN) medicines for staff to follow. Information included signs to look out for; however, further detail was required to include signs the medicine had been effective. For a person who received their medicine covertly (without the person’s knowledge) this was being administered safely and in line with legislation. This included involvement and authorisation from the GP, psychiatrist and persons family member. Controlled drugs, (CD), which are subject to higher levels of legislation for monitoring, were recorded accurately and clearly. Stock was checked daily as part of administration. People were supported to receive their medicines safely. Staff who administered medicines had completed safe handling and administration of medicines training and had undergone an assessment to check their competence to administer medicines safely. We discussed with the registered manager to consider adding more detailed information when carrying out medication competency assessments of what had been discussed with the staff member, any examples given and responses provided by staff members. Medicines were stored safely with access only available to authorised staff. A new area was designated to the management of medicines to prevent distractions and reduce medication errors. Families spoken with did not raise any concerns in relation to medicines. One relative said, “When [person’s name] was ill last year, I was aware of their medications and why.” Family members also said staff consulted with them with any changes regarding their loved one’s medicines.