London Also known as Greenwich

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

The service has been operational since February 2023. The registered manager told us to date there had not been any accidents or incidents, safeguarding allegations or complaints received. Relatives we spoke with also confirmed this.

The service had a policy for staff to follow should things go wrong, and we saw there was an incident form template to use should staff need to. The registered manager held regular meetings with staff to discuss concerns and to decide appropriate actions to address those concerns. The registered manager demonstrated a good understanding of how to respond to any such incident. Relevant policies provided guidance about how to respond if necessary.

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.

Relatives we spoke with confirmed their loved ones received a safe service. A relative told us, “Yes, I was involved in the care planning and reviewing of care for my [relative]. The registered manager did ask me questions about my [relative’s] care. The registered manager also phoned and texted me for information.”

The provider also helped people and their relatives to access services like the local district nursing team for further care and support. Relatives told us that they were aware of who they could contact if they needed to raise any concerns.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We found the service was not routinely working within the principles of Mental Capacity Act 2005 (MCA). For example, the initial referral completed for a person confirmed they lacked mental capacity. The provider did not complete mental capacity assessments and best interest decisions for this person in relation to day-to-day care and support.

The best interest meetings under the Mental Capacity Act 2005 are a formal, multidisciplinary meeting to make decisions for someone lacking capacity. Records showed, in this case, the provider did not organise any such meetings.

The provider’s whistleblowing policy was last reviewed and updated in November 2024. However, the provider own policy stated, “Next review date in 12 months or sooner as required.” Hence, the provider was not routinely reviewing and updating their own policies when required.

Relatives told us they felt their loved ones were receiving safe service from the provider and they confirmed they knew how to raise complaints or concerns.

The registered manager told us there had not been any safeguarding allegations since the service became operational. Appropriate systems were in place to help protect people from abuse and neglect. For example, the provider had relevant policies including safeguarding adults and whistleblowing. The safeguarding policy made clear the providers responsibility for reporting any allegations of abuse to the local authority and Care Quality Commission.

Staff were aware of safeguarding procedures. They knew how to recognise and report abuse and were able to tell us the signs of abuse. A member of staff told us, “If I suspected any abuse, harm or neglect, I would report it to my manager immediately. I would call 999 or local police depending on the incident severity. If my manager does not take any steps, I would report it to the safeguarding team in the local authority or CQC.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not always ensure all risks to people’s safety and wellbeing were identified or provided enough detail as to how these should be mitigated. For example, A person had diagnosis of Chronic Obstructive Pulmonary Disease (COPD). No care plan and risk assessment was completed to guide staff in this area.

We also noticed provider did not complete Personal Emergency Evacuation Plan (PEEP) for people using the service. We raised this with the registered manager, and they completed relevant risk assessments.

The care records we reviewed provided information about the person’s family life, hobbies, interests, and lifestyle. People and their relatives were involved in planning care, support, and mitigating potential risks to them.

Staff were aware of the risks to people and the steps they would take to keep them safe from harm. Training records showed staff had received relevant training, such as infection prevention and control, fire safety, and adult safeguarding.

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 did not carry out any environmental risk assessments covering potential hazards in in people’s homes. However, we found no evidence people including staff were harmed. The registered manager later completed environment risk assessments and shared it with us.

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 registered manager told us as they only had 1 person using the service. It was easy to monitor staff punctuality. There was a staff rota in place. The registered manager told us they introduce a system of electronic monitoring to check staff punctuality and that staff stayed for the full amount of time required.

A relative told us, “Staff stays for the full duration of the call. Lateness is very rare. I have no concerns about staff punctuality.”

People’s initial assessments determined the level of support people required in their homes and the rotas showed there were sufficient numbers of staff scheduled to work in accordance with people’s needs.

The provider had effective recruitment and selection processes in place which ensured people were supported by suitable qualified staff. We reviewed staff recruitment files and found that all required pre-employment checks had been completed which were in line with current legislative requirements. All staff undertook a comprehensive induction programme which included opportunities like shadowing, mandatory trainings and supervision meetings.

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.

Staff confirmed they had completed training in infection prevention and control and demonstrated a good understating of the measures to manage and prevent the spread of infection. Staff were provided with personal protective equipment [PPE].

Staff collected PPE from the head office. Staff told us they had access to enough personal protective equipment (PPE) to keep people safe when providing care.

The provider had Infection Prevention Control (IPC) policy in place. However, we found IPC policy was not routinely reviewing and updating their own policy in managing infection prevention control area. This meant staff did not have a clear guidance in this area.

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.

The registered manager told us they were not managing medicines for people currently using the service. People’s relatives had been managing their medicines.

The provider had effective medicines management systems in place. For example, staff had received training in medicines administration and there were relevant up-to-date policies in place. Systems included all aspects of recording such as daily administration and auditing and checking procedures.