YourLife (Shirley)

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 service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

Accidents and incidents were reported, reviewed and used as learning opportunities. Staff completed post-incident assessments to identify causes, trends and actions needed to reduce risks. For example, following falls, staff reviewed contributing factors, involved relatives where appropriate and encouraged the use of mobility equipment. Learning from incidents had also led to practical changes, such as recommending more suitable footwear for a person, which reduced the number of trips and falls they experienced. Staff told us they were encouraged to report incidents and lessons learned were then shared across the service.

The provider did not always maintain safe systems of care. Systems for monitoring care delivery and recording information were not always effective.

The provider had not yet fully embedded its transition from paper-based to electronic care records, which affected the consistency of care monitoring. A review of the service's electronic call monitoring data identified unlogged calls and a number of short call records. Although the registered manager was aware of this and explained this was linked to staff becoming familiar with the system and had introduced additional support, opportunities remained to strengthen oversight and recording practices. Staff told us they sometimes felt additional staff were needed, as when care visits took longer than expected this could result in them running late for subsequent calls. One person's care review reflected this concern, stating that additional staffing would help reduce pressure on staff during periods of sickness or annual leave.

However, people received their planned care. Systems were in place to monitor visits, review outstanding tasks and support continuity of care, including the use of hospital passports for some people.

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.

People told us they felt safe using the service. Staff understood their safeguarding responsibilities and knew how to recognise and report concerns. One staff member described safeguarding as, “protecting us and the clients from harm and danger,” and was able to identify different types of abuse and reporting processes. The provider had safeguarding policies, training and clear procedures in place, and the registered manager understood their responsibilities for raising concerns and making external notifications when required.

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 to people's health, safety and wellbeing were assessed and managed through a range of personalised risk assessments. These covered areas including mobility, nutrition and hydration, continence, mental health, personal care, medication, infection prevention and control, lone working and escorted outings.

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

People spoke positively about their surroundings. One person told us, "I get a lovely wash, everything is done, the staff tidy up, wash up, dry up. What more can I ask for?” Individual environmental risk assessments were in place for each person's apartment, alongside specific assessments for identified risks, including the safe use and storage of emollient creams due to fire risks. Fire safety arrangements included personal fire safety information and assessments detailing any equipment people used. Staff received fire safety training and the provider worked with the fire service to support their understanding of the environment and people's needs.

However, we identified that service dates for equipment had not yet been transferred onto the electronic system, although records were available in the previous paper-based format. The registered manager recognised this was a gap and told us they would ensure this information was added to the new system. This demonstrated that the electronic system required further time to become fully embedded.

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.

Safe recruitment processes were followed to help ensure staff were suitable for their roles. This included obtaining and verifying references and completing Disclosure and Barring Service (DBS) checks. DBS checks help employers and organisations ensure individuals are suitable to work with vulnerable people. Staff described a structured induction programme, which included shadowing experienced colleagues, e-learning and face-to-face training. Training covered key areas such as first aid, moving and handling, medication and dementia awareness. Relatives told us staff appeared "well trained and caring". Although agency staff were used when required, the provider sought to use the same agency wherever possible to minimise the impact of unfamiliar staff supporting people with their care. We saw evidence that agency staff training records were reviewed through staff profiles.

However, we identified one agency worker whose training had expired and required updating. The registered manager responded positively to this feedback and told us they would follow this up with the agency, as the profile may not have been up to date. In addition, while staff had completed catheter care training, they had not yet been assessed as competent to undertake delegated catheter care tasks independently. The provider told us they were working with health professionals to establish a process for completing catheter competency assessments.

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 infection prevention and control (IPC) training and had access to appropriate personal protective equipment (PPE), including gloves, aprons, masks and shoe coverings when required. A relative told us they always saw PPE available for staff to use. Staff understanding of IPC was monitored through spot checks. One staff member told us, “The duty manager carries out spot checks on medication, PPE and our uniform.” This helped ensure staff followed safe working practices and infection control procedures.

The provider did not always ensure medicines were managed safely and records were completed accurately.

We identified recording errors on some Medication Administration Records (MARs), including missing staff signatures and duplicated medication entries. Although audits had identified many of these issues and there was no evidence of harm to people, records were not always completed accurately.

However, systems were in place to support the safe management of medicines. Staff demonstrated a good understanding of safe medicines administration, including obtaining people's consent and carrying out the necessary checks before administering medicines. One staff member told us, "We seek the person's consent and follow the 6 R’s: right person, right medication, right dose, right time, right route and right documentation." Information about medicines and potential side effects was available to staff, medication competencies had been completed, and care coordination staff monitored medicines daily to identify any missed doses. People and relatives were positive about medicines management, with one person telling us they had experienced "no problems" with their medicines.