Channel Court, Sugar Lookout

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

This service scored 72 (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 and recorded. Staff we spoke with knew the procedures to follow. A staff member said, “We have the incident reports in the system, we have to put a detailed description before, during and after. We are debriefed and they have their procedures they follow and go in depth on analysis.” Accident and incidents were analysed and reviewed for patterns and trends and recommendations taken forward. The provider acknowledged where improvements could be made to simplify their systems and tracking of incidents.

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. The service conducted pre-assessments to ensure care packages would meet people’s needs. The service supported people through transitions in their care. For example, from child to adult services or alternative accommodation. This was planned and communicated in line with people’s support needs.

The provider did not always work 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 free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

We received mixed feedback about people’s safety. A family member said their child was, “Completely safe.” However, a relative told us about an incident that had occurred and said, “No, I don’t think [Name of person] is safe. Another family member said, “I am greatly concerned about [Name of person’s] safety. They have been missing. Nobody owned the problem.” A social care professional said, “Their care can be mixed.”

People’s legal status around deprivation of liberty safeguards (DoLS) was included in care plan information. Staff we spoke with understood the principles of the Mental Capacity Act. A staff member said, “We assume the person has capacity.” Mental capacity assessments and best interest decisions were completed. However, for 1 person these had not been conducted for specific areas of care. The manager said this would be addressed.

Staff knew how to identify and report safeguarding concerns. A staff member said, “Yes, I’ve had safeguarding training for children and adults. A register of safeguarding concerns was kept to monitor progress and outcomes. The provider notified the local authority and CQC as 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. People had individual risk assessments. For example, around accessing the community, swimming and transport. People were supported and empowered to engage in activities of their choice and guidance directed how these risks would be managed. Risk assessments were regularly reviewed and updated. A staff member said, “Because of the relationship I have with the children we go through them together and they write their changes. It is their care essentially, they should be leading that.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Risk assessments detailed risks in the care environment and how these were managed. Fire safety had been considered although there were limited details about fire equipment or alarms in the persons home. A business continuity plan outlined how unforeseen circumstances would be managed such as the impact of adverse weather, loss of electronic system or staffing. People had individual contingency plans in the case of emergencies. An on call telephone system supported staff out of office hours. Staff told us calls were always answered and supportive to them.

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 procedures were followed which included employment and police checks. Steps in the recruitment process were monitored for full completion.

New staff followed an induction programme which introduced them to the organisation and key learning. A staff member said, “The induction talked about the company, the policies and how the company works. They introduced us to the administrators and managers.” Staff received supervision with a line manager. A staff member said, “They are useful. They ask me if I’m OK, I can speak my mind if I am concerned. Most importantly they ask you what your goal is and what you want to achieve.” Staff received appropriate training relevant for their role. Relatives told us staff were well trained. A relative said, “All the carers seem very knowledgeable.” Training which needed to be completed or required refreshing had been identified to improve training compliance. The provider had included in their service improvement plan development of their current supervision and training overviews, so these were more effective.

There was enough staff to support people. A staff member said, “Yes there’s enough staff.” Relatives fed back overall people were supported by consistent staff which enabled trusted and positive relationships to develop. Relatives said, “We have a consistent group of carers who know [Name of person] well,” and “We have a regular group of 6 carers, all the staff are lovely.”

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. People’s care plans detailed how infection risks were managed. Guidance was in place for example, about how to support people with effective handwashing. Staff were supplied with personal protective equipment. A staff member told us, “We have gloves, aprons, foot coverings. I contact my placement manager and they are ordered on the day, its quick.”

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. The provider had been proactive in supporting people and working with professionals around the principles of Stopping Over Medication of People with learning disabilities, autism or both (STOMP). For example, 1 person had been supported in reducing and stopping a medicine they had been taking for years which had visible negative side effects.

Medicine Adminstration Records (MAR) did not always include all information in line with recording guidance. For example, the persons GP. Details around how people preferred to take their medicines was not always in their care plan information. However, staff we spoke with were aware of their preferences.

Systems managed and reviewed medicine administration. Protocols were in place for as required medicines (PRN). Some protocols required further details around how people would express a PRN may be required. This was highlighted to the provider. Body maps for topical creams were completed to ensure staff knew when and how to apply. The provider had created fact files on different medicines to ensure staff knew what different medicines were. Regular medicine audits were conducted and actions identified, for example if there was a recording error. Staff had training in medicine administration and checks completed around their competency. A staff member said, “I’ve had all my medicines training including, controlled drugs and epilepsy.”