Consensus Community Support - Surrey

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 since their registration in February 2024. 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.

Since taking up their role at the start of the year, the current service manager had made improvements to ensure that people and staff were actively encouraged to raise and report concerns. Robust systems were in place to support people and staff to do this with confidence and without fear of repercussions. The service manager told us, “We have met with staff and gone through the process of how to raise and report and discussed the policies. And we had 1-2-1 meetings with staff who needed extra support to understand how to raise concerns. I think staff now have a very clear understanding about how to report things.”

A staff member said, “The culture here is so much better. Communication is much better. It’s much more open and transparent.”

Outcomes from investigations into safety events were reviewed for themes and trends with learning from these findings used to inform staff’s ongoing learning and practice.

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.

Systems were in place to ensure people received safe, appropriate, and person-centred care from the moment they started to use the service. To support a smooth transition, people and their families visited the service, met with staff and other service users, and discussed any questions they had.

Comprehensive assessments involving people, their representatives, healthcare professionals, and specialist staff where required, identified people’s needs, preferences, and risks. This information was used to develop personalised care plans, risk assessments, and positive behaviour support plans which were shared with staff before they began providing care and support.

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.

Feedback from relatives indicated people were safe receiving support from the service. A relative told us, “I think [family member’s] happy and safe there. There is always someone with them.” Another relative said, “I feel [family member] is safe at the service. I visit them regularly and I do check what [staff] are doing with them. I feel there is always staff with them and that’s reassuring.”

People were given clear and accessible information about their rights and how they would be supported to remain safe.

Staff received appropriate safeguarding training and understood their responsibilities for protecting people from abuse. They knew how to recognise and report concerns to the appropriate person or agency. A staff member told us, “I know the rules around safeguarding. Never had to raise one, but I know the procedure.”

When concerns were raised, managers ensured timely referrals were made to the local safeguarding authority. They worked proactively with the local authority to implement safeguarding plans where required, helping to protect people from the risk of harm.

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 were supported to take part in activities, outings, and events of their choice. Staff promoted positive risk-taking, balancing people's rights to independence and choice with measures to keep them safe.

Staff understood risks posed to people and were provided with information, guidance and training on how these should be managed to reduce the risk of injury or harm. A staff member told us, “I feel well trained in using equipment. [Person using the service] loves the hoist and this makes it so much easier and gives you confidence.”

Managers undertook reviews of people’s care records and risk management plans to ensure staff had access to current information and guidance on managing risks effectively and promoting people’s safety and wellbeing.

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

Managers assessed and managed risks associated with people’s living environment to help ensure their safety.

Staff completed regular health and safety checks of people’s living environment, and any issues identified were reported to the housing provider to ensure appropriate action was taken.

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.

Managers ensured staffing levels were sufficient to meet people’s needs. Rotas were prepared six weeks in advance, with the appropriate mix of skills and experience allocated to each shift. This helped ensure people received consistent support from a regular team of staff familiar with their needs and preferences. A relative told us, “I think the staff are regular and consistent. They don’t have agency staff. That’s important to [family member] so they see the same faces all the time.”

The current service manager had made recent improvements to ensure staff received regular, relevant training. Staff were supported to continuously develop their learning and practice through supervision and appraisal. A staff member told us, “We get regular training and supervision. The training is brilliant. We do online and face to face training. I have had a recent supervision. They were not good in the past. This time though I got asked more questions and more about me.” Another staff member said, “Now, supervision is being done like it should be done. They are a lot more in-depth and person-centred. Supervision is more useful and is focused on you as a person.”

Safe recruitment practices were in place. The provider completed the required pre-employment checks to ensure staff were suitable to work with people.

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 received appropriate training and support to help reduce the risk of infection in people’s living environments. They had access to personal protective equipment (PPE) to minimise these risks. A relative told us, “When I’ve gone in there, I’ve never smelt urine or unpleasant smells. They keep the place clean. I’ve seen them mopping up spills quickly.”

Managers monitored staff practice through observations and audits to ensure this was in line with relevant standards and national guidance on infection prevention and control. The service manager said, “We do spot checks on staff practice, and they have got a lot better and it’s good. We have shown them how things are done and this has helped build their confidence.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People consistently received their prescribed medicines, as confirmed by our checks of medicines stocks and records.

Staff received appropriate training and support to enable them to safely manage and administer medicines.

Managers carried out checks and audits to ensure medicines were managed and administered safely.

Managers worked with relevant healthcare professionals to reduce the inappropriate use of psychotropic medicines for people with a learning disability and/or autism to manage behaviours.