Chocolate Works Care Village

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 key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager 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.

The registered manager had fostered a no blame culture where incidents were learnt from and shared openly to ensure lessons could be learnt and changes made and adopted.

The service 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 recognised when someone’s health and social care needs had changed. Staff requested the involvement of the relevant health and social care professional to ensure the person’s health and wellbeing could be restored. Staff knew people well and were able to work closely with external visiting professionals to provide a clear handover of people’s situations to ensure safe systems and continuity of care.

The registered manager 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 were protected from the risk of abuse or neglect. Staff had safeguarding training and understood their place in the safeguarding referral system. Leaders appropriately and promptly referred safeguarding incidents to the Local Authority and notified CQC. One person told us, “Yes I feel safe here.” And another person said, “Yes, it is mostly safe here.”

The staff team 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 were at the centre of decisions being made about the management of risk. People were supported with positive risk taking and staff respected people’s choices. Risk assessments were in place to guide and inform staff on how to manage potential risks to minimise harm to people.

The premises was safe and suitable for people living there. The atrium within the premises was exceptional and unique. Being in a grade 2 listed building which used to be a chocolate factory, the provider leaned into this with the heritage of the building used as a basis for decoration themes. The large atrium area at the centre of the building was the hub of the service with meals, activities and a meeting space for people and their families. This is a unique feature which people appreciated and benefitted from. One person told us, “I love sitting in here [the atrium]. It is such a nice open space.”

Some fire doors were propped open by furniture, and some staff told the inspection team they knew they should not be doing this. The registered manager responded to this by sending out a briefing and meeting individually with staff members involved reminding them of fire safety practices.

Staff, visiting professionals and some people and their relatives felt there were not enough staff. While the provider completed a dependency tool which, on paper, showed there were enough staff, this was not the experience felt by people. People told us, “They are short staffed. They don’t have enough staff.” And, “I think there could be more staff.” A visiting professional told us, “I feel that staffing levels could be increased to help with falls, particularly on the middle floor.” Another visiting professional said, “There has been a shift in staffing levels. There are often times that there are limited staff on the floor to offer occupation and engagement.”

Staff were up to date with their training and staff were recruited safely.

The registered manager assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean, hygienic and free from malodour. Staff were trained in infection control practices and correctly followed best practice principles.

The registered manager 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.

Medication was administered safely. Staff had a good understanding of safe medication management and how to respond to medication errors and incidents. Documentation around “as and when required” (PRN) medication needed more information to clearly guide staff, who may be unfamiliar to the person, on when to give this medication and why. There was an absence of locking facility for medication trolleys in the clinic room on one of the floors. The provider responded immediately to this and relocated unused locks into the medication room. People generally felt medication was safe. One person told us, “They [staff] have missed a dose. Sometimes my [time specific medication] is 20 to 30 minutes late.” While a relative told us, “I don’t have any concerns.” The registered manager was aware of improvements needed around consistent safe medication management and had an improvement plan in place.