EVHM LLP - 24 Tower Road West

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• 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 72 (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. However, although incidents were investigated, safety events were not always recorded appropriately.

There were systems to ensure that all accidents, incidents and near misses were reported. Staff told us that people rarely got distressed because they all knew people very well and knew the signs that meant someone might be getting anxious, this meant they were able to de-escalate quickly and offer reassurance. The registered manager or the deputy reviewed all accidents and incidents and where appropriate, action was taken to prevent a recurrence.

Following our site visits, we received reports following two incidents. Records for one were more detailed than the other. We discussed this with the registered manager and additional records were provided. However, records did not name staff involved in the incidents or give a full account of the sequence of events. The registered manager was able to tell us the sequence of events but acknowledged that further work was required to improve records.

When we assessed a sister home in the organisation we gave advice in relation to fire safety records. Following this advice, we noted 24 Tower Road West had introduced a new form to capture more in-depth records. This demonstrated that learning from one service has been transferred across settings to improve 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.

One person had moved from another service within the organisation. This move was supported through ‘Best Interest’ meetings to make sure it was an appropriate move. The person already knew most of the people living at the service and staff checked that everyone was happy for the person to move in. Several visits were arranged to make sure the person made an informed choice and was happy to move. Staff and the person’s relative told us it was a good move for the person.

‘Hospital passports’ were used to share information should people be admitted to hospital. This set out important information for hospital staff to understand people’s individual needs including their daily routines. Staff accompanied people on appointments and hospital stays to promote their safety and comfort.

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.

The manager understood their role in managing safeguarding concerns and making referrals to the local safeguarding team. Staff were able to tell us what they would do if they suspected abuse. They confirmed they had received training and were confident in reporting any concern to the manager who would pass this on for investigation. A relative told us, “I know [Person] is happy, he is always on cloud 9 and always laughing. He makes me smile.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the home was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where appropriate, applications had been made to the local authority for authorisations. All potential restrictions had been assessed to determine if people had capacity to agree.

There were very clear risk assessments and protocols for what to do in certain circumstances should a person leave and not return within agreed timescales. There was an alarm on the front door and side gate so that staff knew when anyone left the premises. This is not restrict anyone from leaving. One person used local shops independently and chose not to have a key. They told staff when they left the building and rang the bell on their return. Everyone else needed support to leave the building.

We observed positive interactions between people and staff, and everyone looked very relaxed in their surroundings. We asked a person what made they feel safe, they said, “When I go out staff come with me, that makes me feel safe.”

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 knew people and the risks associated with their care. Risk assessments were completed to determine the actions needed to ensure people’s safety. For example, one person needed support at times with mobility, and to use the stairs. A referral had been made to the occupational therapist to check if there was any equipment that might support them. There were clear guidelines and risk assessments in relation to the management of emergency medical conditions, and these had been specifically adapted to the individual person’s needs. Some people had difficulty managing their emotions. Staff followed positive behavioural support plans that clearly described the specific actions to take to support people to return to a level of calmness.

Positive risk taking was supported and encouraged in line with the principles of right support, right care, right culture to help people complete tasks they wanted to do, for example cooking and using buses with staff support.

People had individual emergency evacuation plans which highlighted the level of support they required to evacuate the building safely in the event of an emergency. People knew where they needed to go if the alarms sounded. We noted this had also been discussed at a recent resident’s meeting.

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

The garden needed some attention and there was a small pond that was no longer used that either needed to be filled in or repaired. Garden equipment had been highlighted on a recent audit as in need of replacement. The registered manager agreed that there were areas that needed attentions but confirmed that a gardener came to the service once a month. Following our site visit the registered manager told us the gardener had been and the garden was now looking good, and the pond area had been made safe.

Environmental checks were carried out at regular intervals and areas noted for attention were dealt with appropriately. Regular health and safety monitoring ensured that all servicing of gas, electric, portable appliances and water safety were kept up to date. There was an annual maintenance development plan in place for all non-urgent matters. This demonstrated that the organisation was aware of the areas that needed addressing and could plan to address in order of priority.

Staff had completed online training in fire safety. There was information that described the support people needed to evacuate the building in an emergency. People told us what they did when the alarms sounded. The provider had processes to ensure the premises and equipment were maintained in good order.

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.

Staff completed mandatory training and were offered opportunities to complete additional courses for personal development. Staff told us the training was sufficient to meet their needs.

There were enough staff to meet people’s needs. Some people received additional funding for one-to-one hours where required. Some people attended day services, so staff levels altered according to their needs. There were also systems to gain support in an emergency. A staff member told us they had to use the system once when they needed advice. They said, “They responded straight away and checked in the next day too to make sure I was ok.”

The provider followed safe recruitment procedures to ensure people were supported by staff who were safe to support them. Recruitment records included satisfactory references, employment history, and criminal records checks. People had the opportunities to meet all potential staff, and to share their views on each applicant. Once appointed staff received a detailed induction to the service. A staff member told us, “I received a very good induction to the service and then there was time to read care plans, and I was always with someone, so that helped in getting to know people well.”

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.

People told us that they cleaned their bedrooms each week and were supported to do their laundry. It was evident from people’s daily notes that they were encouraged and supported when needed to carry out daily tasks. Staff cleaning schedules were completed daily, and audits were carried out to ensure all cleaning had been completed as planned. A relative told us, “The service is always clean and tidy.”

Infection prevention and control policies were reviewed and updated regularly. Care staff had received training in infection prevention and control and had access to personal protective equipment. Staff had completed food hygiene training to ensure that they understood how to handle, prepare, and store food properly to prevent illnesses.

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’s medicine cabinets were in their bedrooms and staff supported people with their medicines. There were systems to monitor the temperature at which medicines were stored. Records were kept that detailed how each person liked to receive their medicines. There were also protocols for the use of ‘as required’ medicines for pain relief or in some cases anxiety/distress, along with guidance on how staff would know when to give each medicine.

Staff had accurately completed people’s medicines administration records, which confirmed that people using the service had received the correct doses of medicines at the right times.

Staff received medicine related training which supported them to safely carry out their role, and they were assessed on at least three occasions in terms of competency before they started to support people with their medicines. People received an annual health review of their medicines.