8 Cosway Court

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 registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 62 (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. There had not been any incidents, accidents or complaints at the service since it registered in 2024. The manager told us, “If there was an incident, we would first check to see if there were any injuries, complete an incident form and inform the next of kin. If it was a safeguarding incident, we would get the CQC involved and the local authority. We may need to collect statements.” Staff told us, “When filling in our incidents or accidents form, we follow our Incidents or accidents policy. We currently have two different forms.”

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 manager explained how they supported people with healthcare appointments where required to support safe systems of care. The manager told us they would introduce ‘hospital passports’ to support the safe transition into hospital settings.

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. There was a safeguarding policy for staff which clearly outlined procedures and was in line with legislation. All staff had completed training in safeguarding and had a good understanding of how to protect people from abuse. Comments from staff included, “Our company have a zero-tolerance policy towards abuse. Here safeguarding is everyone’s responsibility, and we empower every member of staff to be the eyes and ears of the service,” and “I look out for abuse by keeping my eyes peeled and knowing the individuals we support like the back of my hand. I am trained to recognising things aren’t quite right even if there are no physical signs of abuse and identifying subtle changes in behaviour or mannerisms.”

The provider did not work with people to understand and manage risks. People’s care plans did not contain enough information to help people manage risks effectively. For example, one person’s care plan did not include any information about their medical history and stated ‘TBC [to be completed]’. This meant staff were not aware of the person’s medical background which put the person at risk. The person confirmed they had a medical condition which posed significant risks. However, there was no risk assessment for this condition.

The care plan also lacked detail on how the person should be supported with personal care, which stated ‘I need assistance’ to various aspects or care with no further detail. This put people at risk of poor hygiene or having personal care carried out incorrectly.

The provider detected and controlled potential risks in the care environment. However, they did not always make sure equipment, facilities and technology supported the delivery of safe care. The service had a health and safety law poster; however, they told us this was displayed in a person’s house rather than the registered office. This meant there was a risk of new staff not having access to important information regarding health and safety.

The manager told us a person had equipment to help them mobilise, but there was no information about this within the person’s care plan. Additionally, there was no evidence of any safety checks on equipment. This meant there was a risk the equipment was not safe to use. However, the manager told us the equipment was checked every week but not documented. The service had completed environmental risk assessments of people’s homes to ensure staff could work safely. Staff had completed mandatory training in health and safety, fire safety and moving and handling.

Staff worked together well to provide safe care that met people’s individual needs. Staff had completed a wide variety of training relevant to their role. The service had not recruited any staff, as the staff providing care were directors of the company. However, the service had the appropriate documents readily available for any potential new staff, such as health questionnaires and interview questions. The staff working at the service had a current and up to date DBS [disclosure and barring service check] and a full employment history. The manager told us all 3 staff met regularly, however there was no evidence of any formal supervisions taking place at this time. The manager said, “We have ongoing communication via [messaging platform], and we also meet face to face. We do spot checks too but don’t record these.”

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 had completed training in infection prevention and control. There was a policy for staff which referenced relevant legislation and was in line with best practice. Staff told us they had access to PPE. One staff member commented, “We have central PPE allocation formal to all support workers. They contain aprons, gloves of all sizes fluid repellent masks, and eye protection. We have good stock control which help us to place an order when we start to run low.”

The provider did not always manage medicines safely. People’s care plans did not have clear information about the level of support required from staff. For example, one person’s care plan stated staff should prompt them to take their medicines, and record whether this had been taken. However, staff and the person told us they managed their medicines independently.

However, staff had received training in medicines administration, although only one out of 3 staff had received a competency check. The manager told us they would introduce these for all staff once staff started supporting people with medicines. There was a medicines policy which provided detailed guidance for staff.