Luke's Place

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. At our last inspection under the previous provider, we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At our last inspection under the previous provider, we found they were in breach of regulation related to safe recruitment of staff and staff training. At this inspection we found the breach had been met.

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. Where incidents occurred, lessons learnt had been identified by the management team, however there was not always evidence the lessons learnt were embedded into the service in a timely way. For example, there was an identified action that staff required competency spot check on their performance and interactions with people they supported, however this had not been actioned at the time of the inspection nor where their clear timescales set as to when this would be completed.

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 and the transitions were meaningful and had people’s needs at the centre of the decisions being made.

A professional said, “I have found the support that people were receiving as very personalised and professional. You had a sense that every individual and their family mattered, I do feel well-being is supported as well as physical health everything appeared tailored and individual.”

People were supported in a way that promoted their safety, independence, and personal choice. People looked comfortable in their own home. A relative told us, “I feel [relative] is safe here.”

Staff demonstrated a clear understanding of safeguarding procedures and acted promptly to address any concerns. Where safeguarding occurred the management team ensured this was investigated appropriately and immediate action was taken to keep people safe.

People’s risk assessments were person-centred and regularly reviewed, enabling people to live as independently as possible while remaining safe. These assessments considered both physical and emotional wellbeing. We found 2 occasions where staff had not followed people’s risk assessments which put people at risk. The management team took immediate action to ensure people were safe.

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 had individual risk assessment around fire risks and the provider ensured there were effective fire safety procedures.

People had their own safe, well-maintained space within the home that met their needs and was a safe environment for staff to work in.

People were supported by staff who had the right skills. Staff received regular training and supervision to ensure they had the skills and knowledge to support people effectively. This included face to face training which considered the individual health and wellbeing needs of the people they supported to ensure staff were best skilled to support them. This included areas such as autism, learning disabilities, manual handling, safeguarding and interactive/simulation training sessions. Staff felt they had the right skills to do their role. A staff member said, “Yes, I do. My skills have become top-notch over time, and I genuinely feel invested in. I take every training seriously; to whom much is given, much is expected. I use what I learn daily. I’m always open to more training, especially advanced mental-health support, epilepsy refreshers, and anything that strengthens person-centred care.”

The provider had a safe recruitment process; appropriate checks were undertaken to help ensure staff were suitable to work at the service. A disclosure and barring service (DBS) check and satisfactory references had been obtained for all staff before they worked with people. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Where staff were recruited from the previous provider recruitment records showed some gaps in staff employment, education experience and interview documentation. Since the provider has taken over, the provider had made effort to improve those documents.

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. This was evidenced through audits completed by the management team. The home was clean. Where appropriate staff wore personal protective equipment.

Medicines were managed safely, and people were supported to take their medicines in a way that suited them, promoting independence where possible. Staff understood people’s needs and preferences with medicines and ensured these were followed. The medicines administration records showed people received their medicines in line with the prescribers’ instructions.

Additional documents to support staff to give ‘when required’ (PRN) medicines were in place. When a PRN medicine was given staff recorded why it was needed. However, records for medicines used to manage some health conditions sometimes lacked detail. We did not see that medicines were administered outside the necessary requirements, however there was a risk that this could occur.