Cleveland Villa

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 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.

The provider had effective systems in place to review and investigate accidents, incidents and safeguarding concerns. Lessons were learnt to continually identify and embed good practice.

The management team ensured investigations of accidents and incidents took place to determine what actions were required to reduce the risk of recurrence. As well as evidence of individual staff reflective practice, the registered manager explained that regular documented team meetings were used to discuss any areas where lessons could be learned or improvements made.

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.

There were systems in place to ensure people’s needs were assessed before they started using the service. The provider ensured there was an individual plan in place for people to ensure they had a smooth transition when they started using the service, this included working with people in their previous environment and observing their needs. People had care plans and risk assessments which were based on these assessed needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

People and their relatives raised no concerns about their safety. One relative told us, “The staff are all great and I know [family member] is safe.”

Staff told us and records confirmed that they had received safeguarding training. They were able to tell us the action they would take if they had concerns. One staff member told us, “I’ve done lots of online training and some face to face, I’ve completed safeguarding training while I’ve been here.” There were safeguarding procedures in place to ensure concerns were identified and reported.

Depravation of Liberty Safeguards (DoLS) were in place, regularly reviewed and applied using the least restrictive approach. Staff involved people, their family, and professionals in decision-making, helping to build autonomy and trust.

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.

There was a system in place to ensure care plans and risk assessments were reflective of people’s needs. The leadership team worked with the people, their families and professionals to ensure care plans and risk assessments were developed individually.

We observed staff providing appropriate support to mitigate any potential risks. For example, we saw members of staff providing safe care to support people to access the kitchen area of the service.

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

We undertook a walk around of the home and saw the premises and equipment were well-maintained which helped support staff to deliver safe and effective care. We noted the eaves in the main bedroom were particularly low due the style of the property, however staff told us they were vigilant to this risk and that it had not presented a problem. We also noted the stairs of the property were steep and narrow, however the registered manager told us that this did not currently pose a risk to people who used the service, or staff.

Detailed records were maintained for all servicing and checks. There were audits in place to guide the registered manager on checks around the home and the environment. Maintenance and fire risks were regularly assessed, and the fire alarm was tested on a weekly basis. Any areas of concern were discussed in team meetings.

Staff had received relevant and good quality training in evidence-based practice. This included in-depth training for people with a learning disability including communication and positive behaviour support.

The provider operated safe recruitment practices, including disclosure and barring checks. These checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. We identified some gaps in records relating to references and an application form; however, the registered manager assured us that these documents had been acquired but had not been filed correctly.

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 saw the home was clean and people were protected from the risk of cross infection. Staff told us they had received training and there was enough Personal Protective Equipment (PPE) available for them to use. There were processes in place to ensure concerns with infection prevention and control were identified so that appropriate action could be taken.

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.

We saw medicines were stored and administered safely. There was guidance in place for staff to follow for ‘as required’ medicines. Staff administering medicines had received training and their competency was checked to ensure they were safe to continue to do so. Medication was counted twice daily to ensure accurate stock levels were maintained.

The provider kept a copy of medication records within the Personal Emergency Evacuation Plan (PEEP) folder in the event of an emergency. When this documentation was reviewed, we found some information relating to medication had not been updated. This omission was rectified immediately.