Opal House

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 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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons learned from accidents and incidents were not being consistently captured or reviewed. The service did not always analyse events to identify trends or patterns that could reduce future risks. Staff did have systems available to raise concerns, and managers responded to these on an individual basis. However, the organisation did not record or evaluate learning from incidents, and there were no formal debriefs documented following accidents or incidents. We discussed this with the registered manager who said they would take action to address this.

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.

Pre-admission assessments and transition planning was robust and ensured people experienced a safe and well-coordinated move into the service. The registered manager completed thorough assessments before anyone was admitted, enabling the service to fully understand people's needs in advance.

People who may require hospital admission had up-to-date hospital passports in place. These documents contained essential information about individuals’ health needs, current care requirements and key contacts. This supported effective communication and continuity of care should someone need to attend hospital.

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.

Systems to safeguard people from abuse were effective and understood by staff. A safeguarding adult’s policy was in place to guide practice, and staff had completed safeguarding training. They demonstrated clear knowledge of their responsibility to report any signs of potential abuse. One member of staff told us, “I would report any concerns to the senior and managers and if they were not at work we can ring through to on call.”

People felt safe living at the service. One person said, “I feel safe and staff look after me.” Relatives we spoke to also felt their relative was safe with one stating, “100% I feel [relative name] is safe.”

The service was working in line with the Mental Capacity Act (MCA).People were only deprived of their liberty when they were deemed to lack capacity, andthis was in their best interests and legally authorised through the Deprivation of Liberty Safeguards (DoLS).

The service 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. New and emerging risks were responded to timely manner.

Care plans provided clear guidance for staff to ensure people received safe, effective and responsive care and support. Risks to people's health, safety and wellbeing were identified, assessed and appropriately managed to help keep people safe. One person had helped develop their own risk assessment, alongside the provider and their advocate to ensure they can access the community in a safe way, identifying positive risk management. The person said, “I can request and choose when I have this support. I hope I may become more independent.”

The provider had effective systems in place to identify and manage environmental risks, helping to ensure people received safe care. Equipment, facilities and technology were monitored and maintained to support safety. Regular checks were carried out across the care home to ensure the environment remained safe. Records showed routine monitoring of electrical systems, legionella, water temperatures and fire safety equipment. Personal Emergency Evacuation Plans (PEEPs) were stored in an accessible emergency grab bag. Where concerns with the fire doors had been identified, the provider had taken appropriate action to ensure the environment was safe whilst they were waiting for equipment to be installed.

There were sufficient numbers of suitably skilled and experienced staff deployed to meet people’s needs safely. Rotas demonstrated planned staffing levels were maintained. Staff received regular supervision, providing opportunities to discuss their practice, performance and development needs. A relative told us, “[Relative name] has talked about the staff with me and they are great.”

The provider had recruitment procedures to help ensure suitable staff were employed. Pre-employment checks were completed before staff commenced work, references and verification of employment history where appropriate. These measures supported safer recruitment practices and helped reduce the risk of unsuitable individuals working with people using the service.

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 had access to infection prevention control training and to essential personal protective equipment (PPE). The provider also had an appropriate policy in place. Staff told us there was always plenty of PPE available and understood when they were required to wear PPE.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Where people required medicines to be administered ‘as and when required’ (PRN) appropriate protocols were in place. However, the effectiveness of the medicine once administered was not recorded, in line with best practice guidance. During the assessment the provider identified how they were planning to improve this area of medication administration.

Systems were in place to ensure other medicines were ordered, received, stored, administered and disposed of safely and in accordance with current guidance. Only staff who had completed medicines training and been assessed as competent were authorised to administer medicines.