Legh House Also known as Abbeyfield Legh 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 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.

People and staff were encouraged and supported to raise concerns, they felt confident they would be treated with compassion and understanding.

Staff told us they were updated about incidents and changes; one staff member told us. “We have up to date care plans available and any changes will be updated in handovers before we start our shifts” Records also evidenced Incidents and accidents were discussed in handovers and meetings. This meant that the service was able to identify lessons learned and implement corrective actions to prevent the risk of further safety events.

The registered manager understood their responsibilities regarding legal regulations by contacting relatives or representatives if an incident or accident occurred. This meant that people and their relatives were kept informed of safety events and any mitigating strategies implemented as a result.
 

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.

The service followed a clear and structured transition process to support people moving into the service. This included comprehensive pre-admission assessments to identify individuals’ needs, risks, and preferences. These were regularly reviewed to ensure they continued to reflect people’s current needs. Relevant information was shared with other healthcare services, including hospitals, when required. Essential information was also kept up to date in a hard-copy format for use in emergencies. For example, people had an overview page, which outlined their healthcare and support needs to help professionals provide appropriate care.

Staff worked in partnership with people, their relatives, and health and social care professionals to ensure care plans were person-centred and regularly reviewed. A relative told us, “They’ve gone above and beyond to get to know him and his preferences.”

Staff told us they felt well supported when new people moved into the service and had access to the information, they needed to provide safe and effective care.
 

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.
Staff had received training in safeguarding and understood their role and responsibilities in identifying and reporting concerns of abuse. Information was on display in the service relating to the provider’s safeguarding procedures. As well as a safeguarding policy and procedure, there was a whistleblowing procedure in place.

Safeguarding concerns were documented, reviewed by management, and included lessons learned to reduce future risks.

People told us they felt safe in the service, people’s relatives confirmed this. We observed people were clearly comfortable in the presence of staff and they confirmed they would speak with staff if they were worried about their safety.
 

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.

Staff adopted a balanced and proportionate approach to managing risk and had the appropriate training and guidance to support people safely. People’s choices and independence were respected, enabling them to engage in the life they chose. Health and social care professionals reported that staff responded promptly to changes in people’s needs. One professional told us, “Staff take on board any advice and act on it, doing everything they can to improve people’s wellbeing and reduce risk.”

Risks to individuals were assessed and measures were implemented to minimise them. These included risks relating to falls, pressure injuries, and nutrition and hydration. For example, where people required support with moving and handling, appropriate measures were in place to ensure this was carried out safely, and the necessary equipment was available. Staff received training in moving and handling, and we observed staff supporting people to change position safely, including when using specialist equipment.
 

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

People lived in a safe, clean, and well-maintained environment that met their needs. Systems were in place to monitor the premises and identify concerns such as faulty equipment or trip hazards. Daily and weekly checks of the environment were completed, including water temperatures, fire safety checks, and kitchen equipment. Staff told us repairs were reported and addressed promptly. People and their relatives told us they felt safe.

People had individual Personal Emergency Evacuation Plans (PEEPs) that clearly set out the support they would need to evacuate safely in the event of a fire or emergency. This helped ensure people could be supported quickly and appropriately. Staff demonstrated understanding of the action they would take in the event of a fire.
 

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.

There were enough staff to meet people’s needs safely. Staffing levels were based on people’s individual needs and staff told us they had time to provide care and support in a person-centred way.

Recruitment processes were managed safely. Pre-employment checks were completed, including Disclosure and Barring Service (DBS) checks, references, and proof of identity, to help ensure staff were suitable to work with vulnerable people.

Staff had the right skills and experience to carry out their roles and had ongoing training relevant to people’s needs, such as moving and handling and safeguarding. Staff told us they felt confident in their roles.

There were systems in place to support staff through regular supervision and appraisal. Staff said they felt supported by the management team and could raise concerns if needed. The provider monitored competency to help ensure safe and effective care was delivered. This meant staff were appropriately supported, accountable and competent in their roles, which promoted a positive culture and helped ensure people received safe, high-quality care.

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.

The service was clean, well maintained, and free from malodours. Daily cleaning routines were in place, and the provider carried out regular infection prevention and control audits to monitor standards of cleanliness and hygiene. Records showed these checks were completed consistently, and training records confirmed staff had received appropriate infection prevention and control training.

Staff had access to sufficient personal protective equipment (PPE) and understood how to use and dispose of it safely. Staff told us they followed infection control procedures in practice, and this was confirmed by our observations as well as people using the service and their relatives, who said staff consistently worked in a safe and hygienic manner.
 

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.

People received their medicines safely as prescribed for them, including external preparations, time-specific doses and ‘when required’ medicines. If people looked after some of their own medicines, it had been assessed as safe for them to do this.

There were suitable arrangements for ordering, storage and disposal, and temperature monitoring, including for medicines needing cold storage and those requiring extra security.

Medicines care plans were in place, and risks were considered for people using higher-risk medicines such as anticoagulants, and flammable topical preparations.

Any errors or incidents were reported, so that systems could be put in place to prevent them recurring. Medicines audits took place to identify any improvements that were needed. The registered manager was further strengthening medicine audits to ensure the minor gaps found during the assessment would now be detected. Staff had regular training and competency checks to make sure they gave medicines safely.