AYS Care

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 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.
Staff and families said there was transparency and honesty within the staff team. The registered manager said, “Staff are encouraged to report concerns, and if something happened, I would involve external professionals, investigate and look for learning to ensure mistakes don’t happen again.”

We saw evidence that audits took place to verify that staff were putting into practice the knowledge gained during training sessions. For example, the audits included management of people’s medicine, the environment and people's care planning and risk assessment. T his proactive approach played a key role in safeguarding individuals, while also supporting the ongoing improvement and development of staff skills.

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.

We saw evidence of ‘grab sheets’ used by staff to aid the quick admission of people between the service and hospitals. The registered manager said, “I always go with people to hospital in the event of an emergency, I do not want them to be alone at a time of need. I then keep good communication with health professionals and re-assess the service users’ needs to ensure we can continue their care.”

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.

One staff member said, “If I was concerned that someone was not safe, I would act immediately and not ignore the situation. I would report my concerns to my manager straight away, following the organisation’s safeguarding and whistleblowing policies. I would also take appropriate action in line with the individual’s care plan and risk assessment to ensure their immediate safety. If necessary, I would document the concern clearly and accurately and escalate it further if the issue was not addressed. The safety and wellbeing of service users is always the priority.”

Another staff member said, “I would report to the manager if I noticed anything which compromised the safety of people. If my concerns were not acted on, then I would whistleblow.”

Another staff member said, “People feel safe at AYS because we have an open and proactive culture of safety, if staff, supported people or relatives report concerns we know we will be listened to without blame.”

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.

The registered manager had risk assessed a complex issue to ensure the safety of an individual with mental health needs. The risk assessment was in-depth and included the person and their family. This risk assessment considered the person’s environment and consent to remove personal items needed to reduce the risks. This risk assessment was detailed in the care plan and covered in staff induction. Additionally, the registered manager had purchased an emergency aid to assist in the event something went wrong. The registered manager also completed a monthly audit of the person’s risk assessment, environment and emergency aid. A relative told us they were involved in this risk assessment and considered it every time they brought something for their loved one.

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 environment was very clean and homely. People were relaxed and enjoying social time in the communal space. One relative said, “We knew from the first visit, this was the place we wanted, we waited a long time but it was worth it.”
The registered manager carries out audits of the environment. Assistive technology was in place for people to alert staff if they need assistance.

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.

The provider implemented a training programme for all staff, covering key areas designed to enhance the quality of care offered to people and maintain robust health and safety standards. The training included safeguarding adults, dementia care, infection control, disability awareness and approaches to support mental health wellbeing. The provider required staff to refresh all their training annually, this comprehensive approach ensured staff were well-equipped with the knowledge and skills necessary to deliver effective, safe, and compassionate care.

The provider had systems in place for safe recruitment of staff.

One staff member said, “If I had any concerns about someone’s safety, I would report them immediately to the manager and document them accurately. I understand the importance of acting without delay and following safeguarding and whistleblowing procedures.”

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 registered manager conducted infection control audits to observe and assess staff performance, reinforcing that correct infection prevention and control measures were consistently followed during day-to-day routines.

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.

Staff received appropriate training and had their competency evaluated before being allowed to administer medicines to people. This approach helped to ensure that medicines was given safely and effectively, in line with best practice and regulatory standards. Relatives told us that their loved ones received their medicines as prescribed. A relative said, “My [relative’s] medication is monitored, and my [relative] is stable for the first time.”