Sanctuary Oasis Ltd

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 service since it was registered on 16 May 2024. 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.

People and their relatives told us they felt confident to speak up about any risks to safety. Leaders responded promptly taking appropriate action to ensure people’s care and safety were maintained.

Staff understood their responsibility to report concerns and took action to promote people’s safety. One staff member told us, “I've reported when a client was found on the floor when I arrived. They weren’t injured but I still reported it. I checked the area didn’t have anything on which they could trip. When another person had fallen and got a cut on their arm; I called the office and then 999 to who came and dressed the cut.”

There were clear systems in place to report and investigate all incidents, accidents and complaints. Leaders monitored events, identified risks and trends, and took action to reduce risks and prevent recurrence. Learning was shared with staff to promote continuous improvement and safe practice, demonstrating a positive safety culture.

Policies and procedures ensured appropriate action was taken following incidents, including notifying family members and safeguarding authorities when required.

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.

People told us their needs were assessed when they started using the service. One person told us they and their family member met with the registered manager and the social worker to discuss “the kind of care I would need, my health issues and my wheelchair, and a care plan was written.”

Staff told us communication within the team was effective and that they reviewed care notes to stay up to date with changes in people’s needs. Care was coordinated through effective communication with families and professionals, with referrals made when needed. The provider’s digital care system supported continuity of care by enabling information sharing with relevant professionals and providing key information for hospital transfers and medical emergencies.

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.

People and their relatives felt safe using the service. One person said, “If I ever had any concerns about my safety I would ring the office straight away.” A relative told us, “[Person name] feels safe and is happy with the carers when they are assisting them. They support [Person name] to use their steady [standing aid] and to help them to stand.”

The provider had safeguarding policies and procedures in place. Staff received safeguarding training and understood their responsibility to protect people from harm and report any concerns. One staff member told us, “There is always a strong emphasis on safeguarding, reporting concerns promptly, and following policies and procedures to ensure the wellbeing of clients. Staff are encouraged to escalate concerns immediately so that appropriate action can be taken in a timely manner.”

Effective systems were in place to identify and report safeguarding concerns. The provider notified the local authority and CQC of incidents as required and shared learning with staff to help prevent recurrence and promote people’s safety.

The registered manager and staff understood their responsibilities under the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Records showed that relatives with the appropriate legal authority were involved in best-interest decisions where their family member lacked capacity to make specific decisions themselves.

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.

Risks associated with people’s care needs and support had been assessed, planned for to mitigate these risks and were monitored. A person said, “I had a discussion with them about what I needed, how I was with my mobility and they wrote everything down and put a care plan together; I have a copy of it.” Relatives shared similar feedback and felt they were listened to and expressed no concerns about the care provided and how risks were managed, at home and in the community.

Risk assessments had been completed for areas such as falls prevention, nutrition, and hydration. Some risk assessments combined multiple areas, such as behaviours and environmental risks, resulting in limited or, in some cases, irrelevant mitigation measures. We also identified that a person prescribed a paraffin-based topical cream did not have a corresponding fire risk assessment in place. This was addressed immediately, and the provider reviewed all residents' medications to ensure appropriate risk assessments and care plans were in place.

Care plans provided clear guidance to help staff support people safely and consistently. They included information about equipment used to promote safety and independence, such as shower chairs and mobility aids as well as relevant instructions from healthcare professionals.

People and their relatives were involved in care planning. One person said they were asked about their preferences, including staff gender and visit times. A relative told us they had been involved in developing, reviewing and updating their family member’s care plan as their health improved, and were asked to read, agree to and sign it. This demonstrated that people and their relatives were involved in care planning and reviews where appropriate.

Staff demonstrated a good understanding of risks and how to support people safely. They had access to detailed risk assessments and care plans by using the handheld devices.

Staff and leaders completed a range of training designed to support them in providing safe care and specialist training aligned to people’s needs while promoting independence. Where the provider had agreed to deliver a delegated healthcare task involving a specialist clinical intervention staff were trained to carry out this task and their competency had been assessed.

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

People and their relatives had no concerns about safety. Key safes were used to provide secure access to homes, and initial assessments included checks of the home environment and equipment to ensure risks were identified and managed appropriately. One relative told us the provider requested equipment safety certificates as part of the assessment process, giving them confidence that equipment safety was taken seriously.

We found that the initial paper-based environmental risk assessments were basic and provided limited assurance. The provider told us these were being reviewed and transferred to the digital care system, which included a more detailed home environment risk assessment to support care planning. Despite this, care plans reflected relevant environmental safety measures and provided staff with clear instructions on the checks required before using equipment.

Overall, we found no evidence that people had been harmed as a result of the quality of home risk assessments. The introduction of the enhanced digital assessment process will further improve the quality and consistency of assessment, mitigation of potential environmental risks, supporting safe and person-centred care.

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

Most people and relatives told us that regular staff arrived on time and stayed for the agreed duration of their visits. One person said, “The staff are usually on time; they are very good at letting me know if they are held up at another client and running late.” However, some people raised concerns about inconsistencies in staffing, punctuality, and visit lengths. Whilst people told us their needs had been met, we shared these concerns with the provider.

Rotas were managed through a digital care system accessed on staff mobile phones. Most visits took place as planned, although some missed or unrecorded visits were identified. While management received alerts, records did not always evidence follow-up action. The provider told us they were increasing management capacity to ensure alerts were reviewed, acted upon, and documented consistently.

Staff were recruited safely. Pre-employment checks, including Disclosure and Barring Service (DBS) checks, were completed before staff started work to help ensure they were suitable, competent, and able to carry out their roles safely.

Systems were in place to ensure staff received appropriate training and competency assessments, providing effective management oversight. Staff completed induction and role-specific training, including supporting people with learning disabilities and autistic people. Where people required specialist clinical support, staff received the necessary training, and competency checks to carry out delegated healthcare tasks safely.

Staff told us they felt confident in their roles, and described good team work and communication enabled them to meet people’s needs. One staff member told us, “We have mandatory training both on-line and face to face which is updated annually. The management also do spot checks to make sure I'm doing everything the right way, which I like; makes me feel confident and reassures the client too.”

Feedback from people about staff attitudes, conduct, and the care provided was used to inform supervision, performance discussions and staff development, helping to ensure care was delivered in line with best practice. This demonstrated a positive and supportive approach to staff development and quality assurance.

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.

The provider had policies in place to prevent and control infection. Staff completed infection prevention and control training and were provided with personal protective equipment (PPE). They demonstrated a good understanding of the measures to manage and prevent the spread of infection.

People and relatives told us that staff used PPE consistently when supporting them. One person said, “The carers all wear aprons, gloves, and foot covers. They also always wear their badge and uniform, which I like to see.” People’s care plans identified when PPE was required, such as during personal care or when handling soiled items. This showed that infection prevention and control practices were embedded in day‑to‑day care and helped to keep people safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People were supported with their medicines and were involved in planning of it. Care plans contained guidance to enable staff to support people to remain as independent with their medicines. One person told us, “The carers will check that I have had my epilepsy medication and if I have been prescribed extra tablets [short-term course] for a while, they will remind me to take them.”

One relative told us, “The carers are consistent in applying prescribed cream and they always let me know when we are running short,” demonstrating good practice medication administration and communication with families regarding stock levels. One relative said staff did not always inform them when medication supplies were low. The provider said this would be addressed.

Staff told us they had received the appropriate training and were confident in administering medicines to people, when required. Records confirmed staff training was kept up to date and were assessed as competent to do so.

We found some digital medicine administration records had not been completed accurately. For example, prescribed pain relief that was not given was recorded as ‘not required’ or ‘task already completed.’ While there was no evidence of harm, these errors had not been identified through audits or spot checks, highlighting the need for improved oversight.

The provider had contingency arrangements in place in the event of a digital issues or failure as paper medication records were kept in people's home.