Comprigney Vean

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.
At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

When things went wrong incident reports were completed and these were discussed among the team and with relatives to identify any learning points.
Following any incident the staff involved had a debrief meeting with the registered manager or another senior member of the organisation. For example, following one incident the organisation’s Physical Intervention lead trainer had completed a debrief with the member of staff involved to identify whether improvements could be made to the training delivered to staff. A member of staff told us this had been useful and an opportunity to learn from the experience. They commented, “It’s not always easy to put things into writing, it was (the debrief) an opportunity to talk about how I felt and identify what had gone wrong.”

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 agencies to help ensure the person received consistent and joined up care. An external healthcare professional commented, “[Staff] work collaboratively with our multi-disciplinary team and the family and other partners all working for the client's best interest.” Hospital passports were regularly updated to ensure information remained current and relevant.

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.
The registered manager was in the process of updating capacity assessments to better evidence how people had been involved in the process.
Deprivation of Liberty Safeguard applications (DoLS) had been made. The registered manager and staff continually monitored the restrictive practices in place to check they remained proportionate and the least restrictive option. Staff meeting minutes showed this was discussed regularly and where possible, restrictions had been removed.
People were protected from the risk of abuse. For example, there were robust systems for overseeing the person’s personal monies. Records were regularly audited by the organisation and checked by a relative.
Staff were aware of their responsibilities to report safeguarding concerns. They told us they were confident any concerns would be taken seriously and acted upon. One member of staff commented, “Green Light make it (reporting concerns) easy to do, they are just approachable. Very clear line of responsibilities, specifically about safeguarding.” Another told us, “Green Light are very strong at promoting safeguarding.”

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.

Care plans contained risk assessments which identified any risk and guided staff on the actions they could take to minimise risk. Staff had a positive approach to risk taking and worked to slowly accustom the person to new experiences and routines without causing them anxieties.

If the person became distressed staff had guidance on how to support them to help them manage their distress. Following any period of distress staff spoke with the person about how they had felt and provided any further reassurance necessary.

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 risks were well managed. 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. Cleaning products were stored safely.
There was a large garden where the person was able to spend time relaxing.

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.

There were recruitment processes to ensure staff were suitable for their role. New staff completed an induction and initial training which was regularly refreshed. Staff told us they were well supported and received regular supervision.
There were enough staff who knew the person well, to ensure the person was able to do the things that mattered to them when they wanted. The registered manager told us it was particularly important staff respected the person’s routines in order for them to build trusting relationships with them. Any staff who were less familiar with the person’s needs and preferences worked alongside more experienced staff before they acted as the lead support member of staff. They also completed competencies for supporting the person with their routines at different times of the day so both they and the registered manager could be sure they were confident to carry out the role effectively and in line with the person’s preferences. A member of staff told us, “We need to make sure they (new staff) are the right person. We then pass on the skills we have learnt.”

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 received training in the administration of medicines and had been assessed as competent to provide support in this area. Following any medicine administration errors staff competencies were reassessed and training updated. Protocols to support staff to understand when to administer medicines prescribed on an ‘as and when’ basis (PRN) had been developed. However, staff were not recording whether these medicines had been effective. We discussed this with the registered manage who assured us this would be addressed.
The provider was signed up to STOMP (Stopping over medication of people with a learning disability and autistic people). There was evidence the service was supporting the person in line with these principles.