T Lives Healthcare 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 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 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 legal regulation in relation to people’s safe care and treatment.

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 promoted an open culture in which staff understood how to recognise, record and escalate incidents, accidents and safeguarding concerns. One staff member described stopping care immediately when a person reported pain, making them comfortable, recording and escalating the concern, and waiting for professional assessment before continuing.

Staff were able to describe escalation processes, safeguarding procedures and whistleblowing arrangements, and demonstrated an understanding of their role in keeping people safe. Staff also described receiving training, supervision, observations and competency assessments to support safe practice. People and relatives spoke positively about the care provided and did not raise concerns about staff attitudes towards safety. Following feedback during the assessment, the provider responded by reviewing records and introducing additional auditing and governance processes to strengthen oversight and learning.

The provider did not establish or maintain safe systems of care that enabled people, staff and partner organisations to manage risks consistently. Information about known health conditions, risk management and staff guidance was incomplete or inconsistent across care plans, risk assessments and medicines records. Staff did not always have reliable information about how to manage risks, when to escalate concerns or how support should continue when arrangements changed. These failures increased the risk important information would not be shared or acted on and that people would receive unsafe or inconsistent care.

The provider worked with people, relatives and partner agencies to help protect people from abuse and avoidable harm. Staff demonstrated a good understanding of safeguarding responsibilities and were able to describe how they would recognise, report and escalate concerns both within and outside the organisation. Staff also understood whistleblowing procedures and their responsibility to act if they believed people were at risk. People and relatives consistently told us they felt safe receiving support and expressed confidence in the regular staff who supported them.

People were involved in decisions about how risks were managed, and staff described balancing safety with independence and individual choice. Staff gave an example of using an alert system rather than restricting a person’s movement, enabling staff to respond while preserving the person’s freedom. People said staff asked for consent and respected their decisions, including their right to decline support. This helped people retain choice and control while receiving support to manage identified risks.

The provider had not consistently identified and managed environmental risks associated with people's care and support arrangements. Records reviewed did not contain a sufficiently detailed assessment of some known fire safety risks, and contingency arrangements were not always clearly documented where people relied on ongoing support from staff. A relative told us there had been occasions when alternative staffing arrangements created uncertainty about how support would be maintained if an emergency occurred. The records reviewed did not always demonstrate how assistance could be summoned or how alternative support arrangements would operate. These shortcomings reduced assurance environmental and emergency risks had been fully assessed and planned for.

The provider had sufficient staff with the skills, knowledge and experience needed to support people safely. Staff described receiving an induction, training, supervision, spot checks and competency assessments relevant to their roles. People and relatives consistently spoke positively about regular staff and described staff who understood their needs, respected their choices and provided reliable support. Some relatives reported less consistency when alternative staff provided care; however, feedback about the quality and competence of regular staff remained overwhelmingly positive. This helped people feel safe and supported by staff who knew them well.

Staff understood their responsibilities for preventing and controlling infection and described using appropriate personal protective equipment (PPE), hand hygiene measures and safe working practices. The provider had infection prevention and control procedures in place and staff knew how to access support and equipment if required. Staff said they would notify the manager when they needed PPE, and it would be delivered directly to them.

The provider did not always ensure medicines were managed safely. Records reviewed contained unexplained gaps, inconsistencies between medicines records and prescribing information, and incomplete guidance to support the safe administration of some medicines. Governance systems had not identified or resolved these concerns before the assessment. While we did not identify evidence of actual harm arising from medicines management, the issues identified increased the risk of medicines being omitted, duplicated or administered other than as prescribed. Following inspection feedback, the provider reviewed medicines systems and introduced additional auditing and monitoring arrangements to strengthen oversight.