Re-Create Freedom

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.

The registered manager maintained a log of incidents, including what had been done as a result, to reduce future risks.

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.

Prior to people using the respite service their needs were assessed. This was used to assess if the person was suitable for using the service. People had the opportunity to visit the service before they decided if they wanted to stay there. A relative told us how their family member had visited for a meal to check if they wanted to use the respite service.

At the end of each stay at the service, people’s relatives were provided with a report of what the person had done, including their activities, food and wellbeing. A relative told us they had a communication book, which was shared with the service to ensure any changes or specific needs were shared with the service, and in turn shared with them.

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.

There were systems in place intended to reduce the risks of abuse, this included safeguarding training for staff and a safeguarding policy and procedure. Staff confirmed they had received this training and understood their roles and responsibilities in keeping people safe from abuse.

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.

Risk assessments were in place, which reflected how risks were mitigated. These assessments included what was important to the person and what they wanted to do when they received the respite service. People were being supported to develop their independence skills and had a say in their life at the service, without being restricted.

People told us they felt safe. One person said, “I feel safe and appreciated.”

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 and measures to reduce them, this included the stairs which were used to access the premises. Health and safety checks were undertaken to ensure the environment was safe, including fire checks.

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.

There were enough staff to ensure people could attend their respite visits when they were booked. A relative told us, “There seems to be enough staff who are very kind and compassionate and helpful.”

The registered manager told us there was ongoing recruitment to support the growing demand for the service and the turnover of staff. To support retention, the probationary period had been extended, to ensure staff received more in-depth support to develop in their roles.

Staff received an induction when they started working in the service, including shadow shifts and a pathway of training requirements. Staff were supported to undertake the Care Certificate, which is a set of induction standards staff are to meet. Staff confirmed they received the training for their role. Face to face training was being planned relating to individual’s needs and how these were met.

The registered manager told us their plans for improving staff supervision, with the development of team leaders who would be undertaking supervisions for the care staff. These provided a forum for staff to discuss their concerns, receive feedback and identify their training needs. However, whilst the registered manager told us there were discussions taking place, these had not always been recorded, we were told by the registered manager these would be going forward.

Records showed staff were recruited safely, this was confirmed by staff.

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 service was visibly clean. Systems were in place to ensure the service was cleaned after respite visits. Staff received training in infection control.

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.

We observed the handover of medicines from people’s relatives to staff at the start of respite visits. These were counted and stored securely. A staff member explained the process for disposal of medicines, for example if they were dropped, and the handover back to relatives when the person finished their respite stay. A person told us, “I take medication in the morning, when I get dropped off, they give it to the staff and they help me.”

Records showed people received their medicines as prescribed. We received mixed views from staff regarding the layout of the medicine administration records, which had been developed to support the short term respite service. Some said they found them suitable and others said they were confusing. The registered manager told us they were open to suggestions to improve them if needed.

Staff had received training in medicines management and their competency checked. Any medicines errors were documented, investigated and measures were put in place to reduce future risks