Potters Green

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. Accidents and incidents were analysed and trends and patterns identified to mitigate future risks. We saw a selection of lessons learned documents which had been completed following incidents. Staff and leaders told us how practice had improved to reduce the risk of similar events. Lessons learnt were shared with the whole staff team to ensure they were on board with any changes and understood why practices had changed.

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. Staff and leaders facilitated safe transitions. Documents were in place to pass on information to relevant professionals. These were clear and detailed how people preferred to be supported and gave information about their medical needs. Details of people’s prescribed medicines were also part of the emergency pack. There was also a good system in place when people returned back to the home. This ensured any new information was factored into people’s care plans. For example, any new medication or changes to people’s care and support were documented and care plans updated as required. Relatives were confident people had access to healthcare professionals. One relative said, “Yes, they [staff] do this well, if [relative] sniffles then the GP is here.”

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. Processes were in place to help staff and leaders safeguard people. Leaders had been working closely with the local authority to ensure lessons were learnt based on recent safeguarding concerns. Staff received training in safeguarding and reported concerns without delay. Relatives told us their family members were safe living at the home. One relative said, “Yes, [family member] is safe with the staff there. [Family member] has a favourite staff member and you can tell that [family member] feels safe.” Another relative said, “It put’s our minds at rest [receiving care] as [family member] is supported 24 hours a day. Everything I see seems like it is safe.”

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people’s care and support were identified and managed to keep people safe. Risk assessments measured the likelihood, impact and risk and detailed steps to take to mitigate the risk occurring. For example, 1 person was at high risk of developing pressure areas. Staff ensured the person was supported to change position and alleviate pressure on a regular basis. They also had equipment such as specialist mattresses and cushions to aid comfort and prevent skin damage. During our assessment we observed staff assisting someone to transfer using a hoist. This was carried out in a safe and thoughtful way, ensuring the person was comfortable. One relative said, “They [staff] help [relative] to manage their choking risk. Staff assist and stand by holding their hand.” Another relative said, “[Relative] has 1 to 1 support and is totally supported to be safe and manage risks.” Some relatives were not happy with how risks associated with people’s care were addressed. However, staff were knowledgeable about the people they supported which ensured they were able to minimise risks. One staff member said, “Risks are addressed within individual care plans tailored to each person’s specific needs, preferences, and health conditions. We work in partnership with residents, families, and health professionals to ensure care plans reflect the most appropriate risk mitigation strategies.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Leaders ensured appropriate checks and maintenance of the environment and equipment took place. The management team completed regular walk round checks of the environment and took appropriate actions to address any concerns. People had individual ‘safe environment’ risk assessments which highlighted equipment to be used to support people safely, such as hoists and bed rails. Personal Emergency Evacuation Plans (PEEP's) were in place to ensure people were supported appropriately in the event of an emergency evacuation. For example, 1 person required verbal instruction and reassurances to evacuate the area safely and for staff to maintain a calm environment.

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. During our site visit we found there were sufficient staff available to support people to meet their needs. We also reviewed evidence which confirmed there had been adequate staffing numbers and staff had received training. We received mixed feedback about the numbers of staff and the training however we found. One relative said, “I think they are short staffed, and they have to get agency in.” Some relatives also commented that some staff were not adequately trained. When we asked relatives about staff being knowledgeable and trained, we received mixed views. One relative said, “Some of them [staff] definitely [have training] others not.” Another relative said, “A staff member was asked to go [work] on the complex care dementia unit, and they were not trained.”

Staff told us there had previously been issues with low staff numbers, but this had been addressed and numbers increased to keep people safe. One staff member said, “All staff receive ongoing training in key areas such as safeguarding, infection control, moving and handling, and managing challenging behaviour. This ensures they are well-equipped to identify, manage, and escalate risks appropriately.” The provider had a recruitment system in place which assisted them to recruit appropriate staff. The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions. Staff received training and support to ensure they had the skills and knowledge to deliver safe care. There were enough staff available to support people to meet their needs.

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. We carried out a tour of the home and found the environment to be clean and tidy. The infection control lead ensured correct products and colour coded equipment was available to clean relevant areas and to prevent cross contamination. Staff had access to Personal Protective Equipment (PPE) and used this appropriately. People and relatives said staff followed safe hygiene practices. One relative said, “[Staff] wear PPE all the time, during mealtimes and when doing personal care.”

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. People received their medicines as prescribed by staff who were trained and competent to administer medicines safely. Medicines audits were completed at regular intervals to identify issues and drive improvement.People who were prescribed medicines on an ‘as and when’ required basis, had protocols in place to ensure they received the medicines when they needed them. People and relatives felt involved with medicine management and staff discussed changes with them. One relative said, “They [staff] tell us that the GP came out and say if the medicines are changing.”