Green Lanes Projects

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• 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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the regulation relating to safe care and treatment, particularly in relation to the management of people’s medicines.

This service scored 62 (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 reported accidents, incidents, near misses and other safety events promptly, which were closely monitored by the management team. These were regularly discussed in meetings to promote learning and drive service improvement. The management team implemented action plans following incidents, highlighting what went wrong and the steps taken to reduce the risk of recurrence. This approach enabled staff to continuously learn while improving the care and experiences for people. A staff member told us, “We learn from our mistakes.”

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.

Before people were admitted to the service, the provider carried out a full assessment of their needs, including assessing risks and considering any health and safety requirements. The service collaborated with people, their relatives and health and social care professionals. Staff arranged transition visits to help protect people from anxiety and stress during periods of change.

Where people had long stays in hospital because they were not well, staff maintained regular contact with them, including daily visits where possible. This helped ensure familiarity and continuity of 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.

Staff knew when and how to report concerns. They understood their safeguarding responsibilities, including how to protect people from abuse, neglect and avoidable harm. People told us they felt safe. We observed people mobilising freely around the home, including into the registered manager’s office. This indicated people had freedom and were not subjected to unnecessary restrictions. Where people had restrictions in place, appropriate legal authorisations were sought and clearly documented. There were processes to manage and oversee people’s finances, protecting them from the risk of financial exploitation.

The provider worked with people to understand and manage risks by considering their individual needs and circumstances. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew people well and had developed positive working relationships and ways to support them safely. Risk assessments were person-centred, detailed, and covered various areas related to people’s health, care and safety. Control measures were clearly documented and well-understood by staff.

Relatives felt the service managed people’s safety appropriately. A relative explained how staff anticipated risks and carefully planned support for their loved one. They commented, “Staff are good, they know what they're doing. [Person’s] safety is about constant supervision; you have to keep an eye on them at all times. You have to check on them even at night, and I think they do that.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff conducted regular checks on the physical environment and reported concerns promptly. Additional checks, including water safety, electrical installation and gas safety, were carried out by external contractors. At the time of the assessment, the service was undergoing refurbishment and redecoration. There was a risk assessment highlighting potential hazards and the control measures implemented to reduce the risk of adverse impact on people while work was being carried out.

Staff supported people to take part in regular fire drills to help ensure emergency preparedness. A person told us, “If I hear the fire alarm, I go out.” However, while the provider had conducted an internal fire risk assessment of the building, we were not assured it adequately reflected the complexity of the service or the specific needs of people living there. Following the inspection visit, the provider arranged for an external fire safety contractor to attend the service and carry out a comprehensive assessment.

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.

Newly recruited staff were enrolled on an induction programme, which included training considered mandatory by the provider and working under supervision. They received regular refresher training relevant to their roles and had access to bespoke training focused on people’s specific needs. Staff also received appropriate training in learning disability and autism in line with national requirements. Staff were supported through regular supervision and appraisals.

The provider carried out appropriate recruitment checks to ensure staff were suitable for their roles. Recruitment files contained a range of checks, including DBS (police) checks, identity checks and employment references. However, the provider relied on staff CVs for employment histories, which were not always complete. Although employment gaps were explored during interviews, the provider told us they would review their recruitment processes to ensure employment histories were accurately and consistently documented.

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 premises were clean and tidy. Staff had access to personal protective equipment and adhered to infection control guidance. They spoke to us about how they ensured people’s rooms were kept clean and disinfected. However, we found 2 of the ensuite shower rooms had mould around the edges and in the drain outlet. After we raised this with the care manager, they told us the shower rooms were due for refurbishment, which their action plan demonstrated. They provided evidence following the inspection visit to show the affected areas had been cleaned.

We identified shortfalls in the management and recording of some medicines which placed people at risk of unsafe care and treatment.

We found an expired PRN ('as required') medicine for 1 person. Records showed this medicine had been administered on 1 occasion after its expiry date, demonstrating existing checks before administering the medicine and audits had not been effective in ensuring expired medicines were identified and removed from use, and expired medicines had remained available for use within the service. After we raised this concern, the provider removed the expired medicine, reviewed the circumstances and implemented action plans to reduce risks and prevent recurrence. Records showed the concern was escalated to the GP, who confirmed the person who received the medicine was unlikely to have suffered harm.

For another person, 2 medicines were being managed as PRN medicines, although the medication administration records and medicine labels did not clearly indicate whether the person should receive the medicines regularly or when required. PRN protocols were not in place and the provider could not demonstrate that they had clarified the instructions relating to these medicines with the prescriber. This created a risk of incorrect administration. Following our visit, the provider contacted the person's GP to review these medicines and clarify the prescribing instructions.

The concerns were not identified through the provider’s medicines oversight arrangements and were only identified during inspection, indicating systems were not effective to ensure medicines were consistently managed in line with prescribed instructions.

The provider stored medicines safely and returned excess medicines promptly to the pharmacy. Staff received competency assessments for handling and administering medicines. Where PRN guidance was in place, this was generally clear for staff to follow. We carried out random medicines counts and found no discrepancies. The care manager was aware of the Stopping over medication of people with a learning disability and autistic people (STOMP) programme and told us people were not over medicated.