EVHM LLP - 6 High Beech Close

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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 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.

There were systems to ensure that all accidents, incidents and near misses were reported. These were used to analyse why particular incidents might have occurred and to reflect on what went well and what could be done differently if a similar incident were to occur. The registered manager or the deputy reviewed all accidents and incidents and where appropriate, action was taken to prevent a reoccurrence. We noted some trends and discussed these with the registered manager. It was positive to note that these had also been identified by management and addressed through staff supervision. Wider lessons learned were also discussed with staff.

We found that some of the language used to describe some incidents was not always helpful and open to misinterpretation. The registered manager was able to provide context for these incidents but acknowledged that this was an area they could support staff with further and ensure that this was always picked up and recorded upon before completion.

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 had a process to ensure people were supported to move into the service. The registered manager described their admission procedure. Any person to be admitted would have the opportunity to visit the service to meet with people and staff. If needed, several visits would be carried out to make sure the person made an informed decision, and to enable those living at the service to share their thoughts about the planned changes.

‘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 registered 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 registered manager who would pass this on for investigation.

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 service 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. There was an alarm on the front door so that staff knew when anyone left the premises and they could provide support as needed. All potential restrictions had been assessed to determine if people had capacity to agree.

People told us they felt safe. We saw that during house meetings staff checked in with people to make sure they felt safe. People’s relatives told us they felt their loved ones were happy. One relative said, “[Person] would tell me if she was unhappy.” Another relative told us, “Definitely,” when asked if they felt their loved one was safe at the service. A third said, 100% safe, yes.”

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 were knowledgeable about the people they supported, 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 was at risk of choking. A speech and language therapist had assessed the person’s needs and there were guidelines for staff to follow. We observed staff ensuring that the correct texture of food was provided. 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. A staff member told us they had attended a course recently and learned some useable tips on what to do. For example, they said when a person needs additional support, “I keep my voice low and this helps [person] to calm.”

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. A relative told us, “[Staff member] can spot when things are wobbly for [person]. She has known her for years.”

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 told us where they needed to go if the alarms sounded.

A relative told us they had worried about their loved one using the stairs. However, the home had ensured professional advice was sought and their relative’s needs had been kept under continual assessment to make sure they remained 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.

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. Safety checks had been carried out on fire safety equipment, and a fire risk assessment had been completed.

Environmental checks were carried out at regular intervals; urgent matters were attended to promptly. 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.

Regular health and safety monitoring ensured that all servicing of gas, electric, portable appliances and water safety were kept up to date. Where recommendations had been made as a result, the registered manager assured us that they had all been addressed.

Where appropriate, people had equipment to support their needs and to keep them safe. These included a bed sensor mat and a rollator for outdoor use. There were systems to make sure these were kept in good working 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. The registered manager told us that they were considering staggering the eLearning training next year so that it did not all become due at the same time. Staff told us the training was sufficient to meet their needs.

There were enough staff to meet people needs. A visiting professional told us, “Having constant and regular staff makes it easier for staff to understand the residents and for the residents to relate to the staff.” Some people received additional funding for one-to-one hours where required. Most of the time there were two staff on duty but there were systems in place for lone working, and in the event of an incident, staff could call for support in an emergency. A sister home was also located next door and staff from there could help in the short term until on call staff arrived.

There was a comprehensive house information guide designed for agency staff. This included information about the house and key contacts including information about what to do and who to call in an emergency. There was also information about each person, their regular routines and how they liked to be supported.

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 opportunity to meet all potential staff, and to share their views on each applicant. Once appointed staff received a detailed induction to the service.

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.

There was a rota on display in the dining room that included cleaning tasks that people had chosen to do. For example, cleaning the table, hoovering and loading the dishwasher. People told us that they cleaned their bedrooms each week and were supported to do their laundry. Staff cleaning schedules were completed daily, and audits were carried out to ensure all cleaning had been completed as planned. A relative told us that the service is, “Incredibly clean and tidy and [Person’s] room is clean and homely.”

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 a medicine cabinet in their bedroom 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.