Scovell Street, Salford

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

This meant people were safe and protected from avoidable harm.

At our last inspection we rated safe as Good. At this inspection the rating has remained Good. 

All areas were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to clients and themselves well. Staff understood how to protect clients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely administer, record and store medicines. The service managed client safety incidents well. 

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

There had been no serious incidents in the 12 months prior to this inspection. There were 14 incidents recorded over the 12 months prior to this inspection.

There was one medication error recorded whereby staff had administered medication at the wrong time of day. Following this a full review of medication processes was undertaken. As a result of this managers introduced  a dual-check system during handover to improve oversight and reduce risk of error and a protected medication administration period was introduced to minimise distractions during medication time. 

All staff we spoke with knew what incidents to report and recorded them on the electronic recording system as soon as possible after the event.

Staff reported all incidents that they should report, using an electronic form which was then reviewed by the manager of the service. We reviewed incidents during the inspection which evidenced that an effective process was in place.

Staff understood the duty of candour. They were open and transparent and were aware of the need to give clients and families a full explanation if and when things went wrong. There had been no duty of candour reports in the 12 months prior to our inspection.

Staff received feedback from the investigation of incidents, both internal and external to the service. The feedback was brought to staff meetings and supervision for discussion. Incidents and lessons learned were shared with the other locations operated by the same provider.

There was evidence that changes had been made because of feedback. An example of this was when a client became frustrated when they were unable to verbally express themselves, resulting in punching and damaging an internal wall. As a result of this, relevant risk and communication needs were clearly flagged on the electronic care management system to improve staff awareness and consistency of response. Staff received refresher training in de-escalation techniques to better support clients experiencing heightened emotional distress and additional training was delivered to strengthen staff understanding of trauma responses and to promote more sensitive, preventative approaches to emotional dysregulation.

Staff were debriefed and received support after incidents had taken place.

We scored the service as 3. The evidence showed a good standard. The service 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’s referral and admission processes ensured that all essential information about the client was received to determine if the client’s needs could safely be met. A thorough assessment was completed including requesting information from the GP, probation or mental health services and speaking to the client prior to admission to ensure that the service could meet their needs. Staff sent an information pack out to clients prior to admission. Clients were expected to have completed detoxification prior to admission to the service. Those clients who did not meet the admission criterion were signposted to other more appropriate services.

Staff involved all the necessary healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. This included working closely with the local authority, children’s services and housing providers.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Staff were trained in safeguarding adults and children, and compliance was at 100% at the time of the inspection. All staff we spoke with knew how to make a safeguarding alert and did that when appropriate. There had been one safeguarding referral made in the 12 months prior to the inspection. This was reported appropriately in line with safeguarding procedures and referred to the local authority for consideration. Following review, no further action was taken. The incident was documented in line with the provider’s safeguarding procedures, and notifications were appropriately submitted to both the police and CQC.

Staff could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act. This included identifying racial or homophobic abuse and taking action against it. 

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies such as the local authority, children’s services and the police. Staff sought guidance from colleagues and managers in relation to queries about safeguarding concerns.

Staff followed safe procedures for children visiting the service. There was a Safeguarding Children Policy regarding keeping children safe and staff followed this by ensuring that parents or guardians always accompanied children when accessing the location’s buildings. Children were never left alone with any member of staff or other clients within the building. These measures ensured clear professional boundaries, reduced safeguarding risk, and promoted a safe environment for children, staff, and clients alike.

Staff did not use restraint as part of de-escalation practices within the service. In line with provider policy, and to maintain clients’ safe care and treatment and support abstinence, some items were prohibited from being brought to the service. Additionally personal mobile phones were permitted within the service but were securely stored by staff and accessed only at agreed designated times.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.  They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 4 risk assessments during the inspection. Risk assessments were up to date, robust and included areas such as physical and mental health, substance history and clients’ personal and social circumstances.

Staff involved clients in their risk assessments and encouraged clients to participate in multidisciplinary team (MDT) meetings.

Staff screened clients before admission and only admitted them if it was safe to do so. They knew about any risks to each client and acted to prevent or reduce risks. Staff responded promptly to deterioration in clients’ health and responded to changing risks. They identified these changes through daily engagement with clients and weekly care reviews. In addition, clients completed daily reflections and feelings sheets. These were reflected in risk assessments where necessary. There was a process for staff to follow to reduce the risk of harm following an early discharge. Client records included a plan for clients unexpectedly dropping out of treatment including contacting agreed family members or carers.

Staff communicated with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties. Examples of this included, easy read information, use of visual aids and MP3 players for audio support.

Staff enabled clients to give feedback on the service they received. The service encouraged clients to complete a quarterly questionnaire on topics including environment, staffing, leisure and groups. Staff also gave clients a questionnaire to complete at the point of discharge from the service. 

Staff enabled clients to make advance decisions when appropriate. 

Staff ensured that clients could access advocacy.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular daily, weekly and monthly risk assessments and audits of the care environment. As a result of these processes, carpeting was replaced in identified areas due to a potential trip hazard, reducing the risk of falls; all fire door closures were serviced to ensure full compliance with fire safety standards and to maintain effective compartmentation within the building and the exterior of the property was repointed to address damp penetration, reducing associated health risks. 

There was an up-to-date ligature risk assessment in place. The service was on three floors and although there were potential ligature anchor points, these had been identified and mitigated. (A ligature point is a physical anchor on walls, furniture, or doors that can hold a ligature.) The service did not admit clients who were at risk of ligaturing. 

The service was for female clients only, with another location accommodating the male clients. 

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 3. The evidence showed a good standard. The service 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.

The service had a residential services manager who worked across the three T.H.O.M.A.S sites. There was also a team leader, criminal justice team leader, group worker and 3 whole time equivalent support workers.

Managers had calculated the number and grade of staff required. The service provided a safe space for women, with 67% of keyworkers being female to support a gender-sensitive environment. Staffing levels and roles were determined based on client needs, the complexity of care required, and professional standards. Risk assessments and workload considerations ensured that the right number and mix of staff were always available to deliver safe and effective care. The number of staff matched this number on all shifts. 

The manager could adjust staffing levels daily to take account of case mix. The process was to offer out overtime to permanent staff or approaching bank staff to provide additional cover.

The service rarely used bank staff but when they were used, those staff received an induction and were familiar with the service. 

There were no staffing vacancies at the time of the assessment.

Staffing levels allowed clients to have regular one-to-one time with their named keyworker. All clients were allocated a dedicated keyworker and weekly one-to-one keywork sessions were conducted with each client. 

Staff shortages never resulted in staff cancelling activities as cover was promptly put in place.

Staff had access to the clients' registered GP or called 111 if required during the day. At night time, if there was a medical emergency, staff  called the emergency services for assistance.

There was a lone working policy in place and an on call process, should staff need additional support out of hours.

Staff had received and were up to date with appropriate mandatory training. The target for the service was 95%, and all areas of mandatory training were at 100% at the time of the inspection. Compliance was monitored through a centralised training matrix, with reminders issued to staff before courses expire. Any staff below target were supported to complete training promptly, and repeated non-compliance was addressed through supervision or performance management.  

Mandatory training courses included safeguarding, medication management, infection control, health safety, fire safety, Mental Capacity Act and other role-specific topics. Compliance was reviewed regularly at management meetings and within monthly key performance indicator (KPI) reporting.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean.

All areas of the service were clean, had good furnishings and were well-maintained. 

Cleaning records were up to date and demonstrated that the service was cleaned regularly. Clients were responsible for cleaning their own rooms and the communal areas and there was a rota for chores. Staff said that they supported the clients and that they took pride in ensuring that all areas were clean and well maintained.

Staff adhered to infection control principles, including handwashing. There were handwash signs in place and staff were compliant with infection prevention and control training.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management. All staff had been trained in the handling, storage and administration of medication and there was an up-to-date medicines management policy in place. The service did not prescribe medication, and any detox process was completed externally, prior to admission. At the point of admission, staff completed medication reconciliation and all medications were stored safely and securely in a locked cabinet in a locked office. Staff completed a medication administration record (MAR) chart to record the administration of medication for each client. 

Managers completed a weekly audit of medication and client allergy alerts had been added to the electronic care management system to improve the visibility of risk information. Staff had been trained in the administration of medication. Staff reviewed the effects of medication on clients’ physical health daily in one to one sessions and referred to the GP or other relevant health professional if required.