Pockets of Peace Care Ltd

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 72 (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 provider had systems in place to review and investigate accidents and incidents. Systems were in place for recording and analysing any trends and changes were implemented in response to any lessons learned.The registered manager was open and transparent and demonstrated commitment to drive improvement at the service.

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. People’s needs were assessed before they began receiving support. Information of care needs assessed by the local authority and information from people and their relatives was used to inform people’s care plans and risk assessments and ensure transitions into the service were person centred, well planned and coordinated. One relative told us, “They [staff] did 2 home visits before we started using the service and they went through likes and dislikes and everything about [name of relative], how they liked their routine and everything.”

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 registered manager was aware of their duty to report any concerns to the local authority and CQC but had no recent safeguarding incidents that met the threshold for reporting. People were protected from the risks of abuse and staff were trusted to keep them safe. One relative told us when asked if their relative feels safe and is treated well by staff, “Yes, I would be able to tell if they didn’t and they [family member] do feel safe.” Staff received training in how to safeguard people. Staff we spoke with were confident to report concerns and satisfied that action would be taken to investigate them. One staff member told us, “I would follow the companies safeguarding protocol and would report any concerns to management.” Overall, the service operated in line with the principles of the Mental Capacity Act 2005 (MCA) and other relevant consent frameworks relating to children, including Gillick competence. The MCA establishes a legal framework for making specific decisions on behalf of individuals (aged 16 and over) who may lack the capacity to make those decisions themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised.Gillick competence is used to assess whether a child under 16 has sufficient maturity and understanding to consent to their own medical treatment without parental involvement. While the registered manager and staff demonstrated an understanding of key concepts such as decision-making, mental capacity, and deprivation of liberty, additional training was needed to ensure that all aspects of consent are fully covered across the range of services the provider is registered to deliver. Some care records and communication plans also needed some additional detail around consent and best interest decisions. The registered manager took immediate action including booking training, updating care records, policies and templates and contacting appropriate professionals for formal inclusion in best interest decision-making.

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. Care plans provided guidance for staff to ensure people received safe and responsive care and support. Risks were assessed and mitigated to keep people safe. Risk assessments were person-centred and regularly reviewed and staff received a range of training to support them in managing risk including training in positive behaviour support. Staff were clear of their roles and responsibilities in managing and mitigating risk. One staff member told us, “I manage risk by checking the individual’s care plan before we start, watching for problems during the activity and writing it down if anything changes. If something new comes up, I make it safe, record it, and tell my manager so the plan can be updated. I keep children safe but still let them try new things.”

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 risk assessments were in place to safeguard people and staff whilst supporting out in the community. Where support was provided in people’s home’s, risks were regularly reviewed and if equipment was to be used the registered manager confirmed that checks would be completed to ensure servicing was up to date. The registered manager also agreed to introduce more formal processes of ongoing environmental checks for people’s homes.

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. Staff undertook an induction at the start of their employment, along with ongoing training and refresher courses to support them in performing their roles effectively. However, some staff required further training in key areas, including learning disability and autism and consent. This was addressed immediately by the registered manager and training booked in these areas. Recruitment procedures were in place to ensure people were supported by staff who were appropriately qualified and assessed as suitable to work with others. However, these processes required further strengthening, particularly in relation to employment history, health and obtaining where possible a reference from most recent care employment, to fully ensure safe recruitment practices. The registered manager took prompt action to update recruitment processes to include these requirements. We reviewed rotas and records of visits and noted no concerns. Overall families were happy with call times and consistency. One relative told us, “They [staff] know that [relative] likes a certain routine and that they would be upset if they are late, so they are always on time.” One family member requested more communication around confirmation of calls which the registered manager agreed to action. Staff told us they felt supported in their roles and received regular support and supervision. One staff member told us, “I have supervision every 6-8 weeks where we discuss the people we support, any challenges and my training. We also hold regular team meetings where we share updates and make sure we are consistent. There is also 24/7 on-call for urgent issues.”

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 received training on infection, prevention and control (IPC). No concerns were raised by staff or families about the availability of personal protective equipment (PPE) or management of infection.

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. At the time of our visit no one was receiving support with medicines. However, staff were trained in medicines administration and systems and processes were in place should support in this area be required. The provider had a medicines policy, and this included the principles of STOMP (stopping over-medication of people with a learning disability, autism or both).