Tanglewood

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 81 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

There were effective mechanisms for sharing lessons learned. Accidents and incidents were recorded and reviewed so any patterns and trends could be identified. Following any incident, staff had a debrief with a manager to identify what had worked well and what could have been done differently. Records showed incidents had reduced over time.

Handovers, staff meetings and daily records were used to share information amongst the staff team about what had worked well for people and what had not. For example, one person had become reluctant to use the shower; staff continually encouraged the person and discussed amongst themselves how they could try to help build the person’s confidence. Staff demonstrated a ‘can do’ approach to the problem. When an idea did not work, they thought about how they could modify it or try something new. Although they had not as yet been successful staff were persistent and did not give up on trying.

Staff had clear information to support them when identifying what needed to be recorded as an incident. This meant there was a consistent approach to recording which underpinned strong data collection.

Staff meeting minutes showed staff discussed possible triggers for anxiety and how these might be avoided. For example, furniture had been rearranged so people were not walking behind one person as this could cause them distress.

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.

Staff worked closely with other professionals to help ensure a joined up approach. People had access to GP’s, occupational therapists and other specialist healthcare professionals. Hospital passports had been developed so hospital staff would have access to relevant information about people’s needs and preferences if they needed to be admitted. One hospital passport was out of date. The registered manager told us they would address this.

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 Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.
Mental capacity assessments were completed to evidence when people lacked capacity to make decisions. The provider had developed a template for recording capacity assessments and best interest decisions. This included prompts for staff to evidence how people had been supported to be involved in the process. We saw examples of these and noted they described how information had been presented and how the person had responded.
Deprivation of Liberty Safeguard (DoLS) applications had been made when required. Restrictive practices were monitored to help ensure they remained proportionate, in the person’s best interest and the least restrictive option. A physical intervention training manager reviewed all restrictive practices annually.
Staff had completed training in safeguarding and the MCA. They understood their responsibilities under safeguarding and reported any safety concerns to management. Staff were confident any concerns they raised would be dealt with but were aware how to escalate issues outside of the organisation if needed. The registered manager had reported safeguarding incidents appropriately.

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.

People had detailed care plans and risk assessments to guide staff on how they could mitigate any identified risk. Care was provided safely while enabling people to do the things that mattered to them.

Staff had access to advice from a Positive Behaviour Support team who were able to develop strategies bespoke to people’s needs with the aim of reducing risks over time. When a person’s health condition meant they were at increased risk when distressed, training had been developed so staff were able to support the person safely.
 

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

Checks of utilities and equipment were regularly carried out by external contractors. Staff completed weekly and monthly checks such as vehicle checks and fire safety checks. Fire evacuation drills were completed regularly to help ensure staff and people knew what to do in the event of a fire.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Green Light developed bespoke physical intervention training to ensure staff had the skills necessary to meet people’s needs. The training had been accredited by the British Institute of Learning Disabilities (BILD). The training had been adapted to meet the needs of one person with some additional physical needs.
In addition, Green Light provided training for supporting people with (obsessive compulsive disorder (OCD) and Intensive Interaction, a recognised technique for supporting communication with people who do not use words.
A training matrix showed staff had completed training in supporting people with a learning disability and autistic people. Arrangements were being made, at the time of the inspection, to provide the preferred and recommended training on learning disability and autism for health and social care staff across the organisation.
A dedicated Positive Behaviour Support (PBS) team structured and delivered PBS training across the organisation. If needed, training for specific individuals was developed and provided to relevant staff. This showed training was planned and delivered to meet each individuals needs. There was a flexible and responsive approach which allowed training programmes to be designed according to people’s changing needs.
When one person had moved to Tanglewood from another Green Light service, staff who knew them well had moved to work at the service so they could work alongside other staff and help ensure care was provided in line with the person’s needs and preferences. This meant the person received consistent care from staff they had already built trusting relationships with alongside staff they did not know.
New staff were recruited safely and completed an organisational induction before starting work. New staff were matched to specific services to help ensure ‘a good fit.’
There were enough staff with the relevant experience and skills to support people to live full and meaningful lives. The registered manager organised the rota to help ensure staff skills were appropriate for the needs of people and the activities planned.

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.

Staff were trained in Infection Prevention and Control (IPC) and were provided with Personal Protective Equipment (PPE) when carrying out personal care. They supported people to maintain a clean environment. The service was clean and tidy; checks were in place to monitor the cleanliness of the home.

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.

Staff had received training in the administration of medicines and were assessed as competent to provide support in this area. Following any medicine errors staff competencies were reassessed and training updated.
Medicines were kept securely in an office. We discussed with the registered manager how people might be encouraged to have medicines kept in their own rooms if they wished, to help develop a more independent and private approach.