EVHM LLP - 25 Alexandra Road

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.

Staff felt comfortable to report any accident, incident or concern. The registered manager encouraged staff to report all incidents so that they could learn from them. This included a review by the managers and the senior managers to ensure appropriate actions were taken to reduce any immediate risk along with steps taken to prevent a reoccurrence. Lessons learned were discussed and put into practices to keep people safe in the future.

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 had been no new admissions to the service for many years. The registered manager told us what their policy would be before any admission, people would have opportunity to visit the service. They would spend time with other people and staff so that they could make an informed choice about moving in. People’s relatives told us they were involved in discussions about their care needs.

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 safety and comfort for people. Some of the information within the passports required clarity, the RM stated they would address them to make it clearer.

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 received training in safeguarding and told us they would report any concerns about people or staff conduct to their manager in the first instance. The registered manager understood their role in raising and managing safeguarding concerns and making referrals to the local safeguarding team. The registered manager told us that during staff meetings they checked that staff were aware of the correct procedures for reporting any concerns. None of the residents were deprived of their liberty, however an application for a potential restriction had been raised with the authorising body as requested by the local authority. In the interim, there were clear risk assessments and protocols for what to do in certain circumstances should the person leave and not return within agreed timescales. There was an alarm on the front door so that staff knew when anyone left the premises.

We observed positive interactions between people and staff. We asked a person if they were happy at 25 Alexandra Road, they replied, “Of course I’m happy here, I have staff to talk to.” We asked if there was anything that made it unsafe and they said, “Not much, I got a new rug.”

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.

Individual support plans included a range of risk assessments that considered the person's environment, care and treatment, medicines and activities. Support plans informed staff of what actions they needed to take to keep people safe and reduce the risk of harm. Where a need was identified, people were referred for specialist support to ensure risks were managed effectively and safely.

Staff were able to talk about the actions they took to minimise the risks of situations escalating and how they kept people safe. They kept records of any actions that indicated people might be distressed. Records did not always demonstrate that a debrief had been held with the staff concerned following incidents. However, following a recent incident, it was clear that actions had been taken to support staff. For example, following a request to management, a decision had been taken to enable female staff to work at other services to enable them to have a break. A staff member told us, “We moved around more and we were listened to when we expressed concerns.” Staff told us that during a recent incident people were upset and needed staff support to make them feel safe. Staff recognised that people could make unwise decisions and they supported people when these situations arose.

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

All 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, and they were clear they needed to go to the organisation’s sister home that is situated close to the service. The provider had processes to ensure the premises and equipment were maintained in good order.

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.

People were supported to arrange their rooms as they chose, for example, one person chose to buy a desk and the company then bought them a chair. They chose both and then rearranged the layout of the room. Although the layout was not ideal in terms of access to clothes, they were happy with it and wanted it to stay the way they chose.

The provider ensured there were enough qualified, skilled and experienced staff who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

All staff were up to date with their mandatory training and staff were offered opportunities to complete additional courses for personal development. Although staff had completed online training on mental health, they said this was not sufficient to meet their needs in supporting people living at the service. The registered manager confirmed that she had been trying to source appropriate training to meet their needs. Apart from the area of mental health, staff told us the training equipped them to carry out their roles. Following each online training all staff complete a quiz and had to reach 100%. Staff told us they attended regular supervision meetings.

People received additional funding for one-to-one hours where required. There were systems in place for lone working and in the event of an incident staff could call for support in an emergency. This was rarely needed but there had been occasions when staff had to call for support. All the staff told us that when these occasions arose, they did feel concerned. We raised this and the registered manager confirmed they would review the staffing arrangements.

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. Staff received a detailed induction to the service. There was an on-call service for out of hours advice and support. People were involved in interviewing potential staff, and they had opportunities to meet all new applicants and their opinions were documented.

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.

One person told us they had a day each week when they were supported to clean their bedroom. They told us they took their laundry downstairs for washing. Cleaning schedules were completed daily, and audits were carried out to ensure all cleaning had been completed as planned. A relative told us, “The home is kept clean, tidy and efficient.”

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.

Each person had guidance in place that clearly demonstrated how they either told staff or indicated if they needed pain relief and how they like to receive medicine, when required. 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. One person’s medicines were stored in their bedroom and another person’s medicines were stored in the office at the person’s request.

Staff received medicine related training which supported them to safely carry out their role safely and they were assessed in terms of competency before they started to support people with their medicines. People received an annual health review with a pharmacist from the local MOCH (medicines optimisation in care homes) team.