EVHM LLP - 5 High Beech Close

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 service had a proactive and positive culture of safety, based on openness and honesty. Staff reported safety events. Lessons were learnt to continually identify and embed good practice. Staff told us that when incidents and accidents occurred, any learning from these was shared with them through staff meetings and individual supervision meetings. People and relatives told us they felt comfortable raising concerns. A person told us, “I can tell any of the staff if I have any worries, but I am very happy.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

People had a hospital passport to take with them should they be admitted to hospital. This set out important information for hospital staff to understand risks associated with meeting their individual needs. People also had individual health action plans to support the sharing of information between relevant healthcare professionals. Staff supported people to attend healthcare and hospital appointments to share information and record advice received.

The service 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.

During our assessment people were relaxed with staff and approached them confidently when they wanted support or interaction. Relatives felt their family members were well cared for and safe. A relative told us, “Yes she is safe, the staff are good.” A person told us, “I do like living here, staff don’t tell me off, they talk to me and that helps me feel safe. I have a mood chart to help me with my emotions.” Another said, “It’s a good place, they lock the doors at night.”

Staff received training in safeguarding and told us they would report any concerns about people to their manager. The registered manager understood their role in raising and managing safeguarding concerns and making referrals to the local safeguarding team. When people were identified as potentially being deprived of their liberty, applications were made to the authorising body as required.

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. One person was waiting on an assessment for an occupational therapist in relation to their use of the stairs. Staff understood the actions they needed to take to keep people safe.

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

Environmental audits 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. Staff had received fire safety training and information described the support people needed to evacuate the building in an emergency. 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.

The provider followed safe recruitment procedures to ensure people were supported by staff who were fit and safe to support them. Recruitment records included satisfactory references, employment history, and criminal records checks. Staff received a detailed induction to the service. A staff member told us they had received a very good induction to the service. One staff member had a range of training that had not yet been completed. The registered manager told us the staff member would be supported to complete this in a timely way. The staff member was an experienced staff member. Staff told us they received regular supervisions to support them to do their jobs well.

A person told us, “I think they have enough staff, one at night and one or two during the day. A person’s relative said they thought there could be more staff at the weekends sometimes. The registered manager told us that they provided additional staff if required based on the needs of people, daily activities, or if people had appointments. The rotas demonstrated that this was the case.

The provider assessed and managed the risk of infection. A relative told us, “The place is always very clean.” People told us they had a day each week when they did their laundry and were supported to clean their bedrooms. Cleaning schedules were completed daily, and audits carried out to ensure all cleaning had been completed as planned. The registered manager and deputy told us they did random spot checks.

Care staff had received training in infection prevention and control and had access to personal protective equipment (PPE). Staff knew when and how to use PPE correctly and how to prevent the risk of infection. 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.

Care plans gave information for staff on how to support people with their medicines. However, information for “when required” (PRN) medicines was not always detailed enough. We discussed this with the registered manager, and they agreed to provide a greater level of detail. This had little impact for people as all the staff team knew people well and they did not use agency staff. An assessment of how people indicated when they were in pain and if they were independently able to ask for pain relief had been carried out. 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.

A nurse practitioner either rang or emailed the service weekly to check if people had any medical issues they needed support with. Staff received medicine related training which supported them to safely carry out their role and they were assessed in terms of competency before they started to support people with their medicines.

A health professional told us they had visited unannounced, and all records were, “Perfect.” They said that last year people had been taken off some of their medicines with a planned approach and this had worked very well.