Cabrini House 3 (Diagrama Healthcare)

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. At our last inspection we rated this key question Good. At this inspection the rating has remained Good. This meant people were safe and protected from avoidable harm.

We did not assess all the quality statements within this key question. We did not identify concerns relating to these areas which we judged as being met at our last inspection.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

There were systems in place to safeguard people from abuse. Staff told us they had received training on safeguarding adults from abuse, and they felt confident any concerns they raised would be managed appropriately. A person using the service said, “I feel that I am very safe living here.” A relative told us their loved one was safe. Their loved one had lived at the service for a long time, and the staff knew them well. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether any restrictions on people’s liberty had been authorised and whether any conditions on such authorisations were being met. We found that people were consulted and supported by staff to make choices and decisions for themselves. Staff were aware of seeking consent from the people they supported and had received MCA training.

There were systems and processes that protected people from avoidable harm. People had individual risk assessments in place relating to for example medicines, personal care, self-injurious behaviour, eating and drinking, and accessing the community. We saw guidelines were in place for staff to follow to manage these risks for example supporting people to eat and drink safely and using equipment in the kitchen. People also had individual emergency evacuation plans in place which highlighted the level of support they required to evacuate the building safely in the event of an emergency. People received safe care from staff who understood and managed risks effectively. We observed staff supervising people whilst they prepared their breakfast in the kitchen.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. We observed there were enough staff deployed at the service to meet people’s needs and keep them safe. Staff told us there was enough staff to meet people’s needs. A person using the service told us, “There are enough staff here all the time to make sure everybody is ok.” A relative commented, “There always seems to be enough staff and there always someone to talk to.”

The provider had safe recruitment procedures in place. The registered manager told us a person using the service recently took part in recruiting staff. The person had questions to ask applicants, and they were able to put their views across when deciding whether to employ the applicant. Staff files indicated all necessary pre-employment checks were completed before staff commenced employment. These included checks on employment history, references from previous employers and Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff completed training in areas relevant to peoples care and support needs. Staff completed an induction in line with the care certificate when they started work at the service. We saw a training matrix, this indicated that staff had received training on epilepsy, diabetes, fire safety, health and safety, first aid, food hygiene and moving people, safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Staff had also received Oliver McGowan training; this was a training program aimed at improving the care and support provided to autistic people and people with a learning disability.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People received their medicines safely and as prescribed. One person told us, “I come downstairs to the medicines room every day and the staff help me to take my medicines.” A relative commented, “When my loved one comes home the staff count and sign out medicines and sign and count them when my loved one returns to the service. Medicines are well organised, they have a strict policy, everything is very thorough.” Medicines were stored safely and administered by trained staff who had completed up-to-date medication competency assessments. We saw medication administration records (MAR charts) were completed accurately by staff, with codes for non-administration where appropriate. PRN (as required) medicines protocols were in place to guide staff on when to administer these medicines. People had individual homely remedy medicines signed by their GP. A homely remedy is a medicine used to treat minor ailments.

The service complied with STOMP (Stopping the over medication of people with learning disabilities, autism or both). This was a national project to reduce the inappropriate and excessive use of psychotropic medicines for people with a learning disability and or autism. Regular monthly audits of medication practices were carried out to make sure medicines were managed safely.