1, 2 and 3 St Georges Gardens

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, investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

The provider demonstrated a clear understanding of their responsibility to record accidents and incidents and to take steps to reduce the risk of recurrence. Robust systems were in place, including an accident and incident reporting policy and procedure. Staff were confident in how to record incidents and understood the importance of accurate reporting.

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.

Information was gathered from people, relatives and others involved in their care and support to understand their individual needs and any risks to their safety. This informed the development of personalised care and risk management plans. This ensured people received safe and appropriate support from the moment they began using the service. The registered manager explained that they always worked closely with people’s families and relevant health and social care professionals.

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.

Staff understood their safeguarding responsibilities and followed established processes to raise concerns, helping to protect people from the risk of abuse. Staff told us they had received safeguarding training and felt confident escalating issues to their manager or directly to the local authority. One staff member explained that they monitored body language, facial expressions, and any marks or bruises to identify potential concerns. Another staff member said they would report issues to managers or the local authority. A relative told us their family member felt safe and that staff knew them well and provided very good care.

Managers and staff had received Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training. The service was working within the principles of the MCA. Applications for Deprivation of Liberty Safeguards (DoLS) authorisations were completed, and the CQC was notified when authorisations were granted. DoLS provide essential human rights protections, ensuring any deprivation of liberty is necessary, proportionate, and in the person’s best interests.

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.

Care plans and risk assessments gave staff clear guidance on how to support people safely with eating, personal care, medication, and mobility. Staff understood the risks people faced and how to keep them safe. They were knowledgeable about people’s complex conditions and understood each person’s care needs and preferences.

Staff told us they were fully aware of the importance of people’s individual risk assessments. They said they used them to create strategies to reduce people’s anxiety and to avoid or manage the situations that increase people’s anxiety and distress.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Safety checks of the premises and equipment were completed regularly, and any issues identified were addressed promptly to maintain a safe environment. Emergency procedures were in place, and these were reviewed regularly to ensure they remained current and effective. These measures helped ensure people received care in a safe and well managed setting.

People’s individual environments had been adapted to meet their specific needs and to ensure it was safe for them. One relative told us, “’ Names’ environment has been made as safe as possible for 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.

There were enough staff on duty to meet people’s needs, and staff responded promptly when support was required. Safe recruitment processes were followed, and the staff team provided people with consistency and continuity of care. Staff told us they had regular access to training and development opportunities and felt well supported in their roles. They described a positive team culture, and relatives told us staff were mostly skilled, knowledgeable and confident in their practice. Staff had a good understanding of their roles, responsibilities and understood their accountability.

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. Staff followed safe infection prevention and control practices and used personal protective equipment (PPE) appropriately to help prevent the spread of infection. Staff had completed relevant infection prevention and control training and demonstrated a good understanding of these procedures. The environment was visibly clean and well-maintained.

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.

Systems were in place to ensure people’s medicines were administered safely. Medicines that needed to be given at specific times were administered as prescribed. For medicines taken on a ‘when required’ basis, such as pain relief, clear person-centred guidance was available and reviewed regularly. Staff recorded the effectiveness of ‘when required’ medicines, in line with good practice.

Medicines were stored securely, and the temperatures for the medicine rooms and fridge were monitored to ensure storage remained within recommended guidelines. Staff understood and applied the principles of STOMP (stopping over-medication of people with a learning disability, autism or both), and ensured people’s medicines were reviewed by prescribers, in line with these principles.