Diana’s Quality Care Ltd

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• 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 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 relatives reported that staff listened to their concerns and responded in an open and transparent manner, demonstrating that feedback was appropriately acknowledged and addressed. For example, one person said, ”The manager is there for me on my good or bad days. They listen to any issues I may have. I know that the staff will always help me to find a way to sort out the concern that I may have”.

The provider had systems in place to review accidents and incidents to identify patterns, trends and underlying causes. Learning was communicated to staff to mitigate risks and support continuous improvement in practice.

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 service completed pre-assessments to determine whether people’s needs could be met safely. Records showed people and their relatives were involved in the process.

Care plans and risk assessments were developed following assessment and reflected people’s needs, preferences and identified risks. The registered manager briefed staff on people’s support needs and ensured they had access to these records, supporting the delivery of personalised care.

The provider has introduced a new online care planning system which meant that all document we being transferred on to one system which the staff had access to at all times.

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 told us they felt safe being supported by the service One person said, “The care I receive is very good and I feel safe”.

The provider had Policies and procedures in place which outlined how staff should identify, report and respond to safeguarding concerns, helping them understand their responsibilities.

At the time of our inspection there were no recorded safeguarding concerns.

Training records showed staff had received safeguarding training and understood how to recognise, report and escalate concerns. Staff knew to inform managers and contact the police where a person was at immediate risk. For example, one member of staff said, ”I would report any concerns that I have”.

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.

The provider assessed and managed risks in a person-centred way. People told us that they were involved in identifying and reviewing risks. One person said, “The manager gave me a copy of the completed risk assessment for me to read and agree to”.

Records showed risks relating to falls, environmental hazards and community access were managed to support people’s safety and independence.

Staff feedback showed they were involved in assessing and reviewing risks to people’s health, safety and wellbeing. One staff member said, “information is shared in staff meetings. I also have access to all risk assessment and needs assessments”.

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

The registered manager assessed environmental risks in people’s homes and worked with them to reduce identified risks. Staff were informed of risks and any changes, supporting safe and consistent care.

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.

The provider followed safe recruitment procedures. Records confirmed that identity, references, health declarations and Disclosure and Barring Service checks were completed before staff started work. One staff risk assessment did not contain sufficient detail to demonstrate how the provider had ensured the person was safe to work at the service. The registered manager explained the actions that had already been completed, although these had not been recorded in the risk assessment. They immediately updated the record and sent it to the inspector.

People were supported by staff who knew them well and understood their communication needs, routines and support requirements. Staffing arrangements reflected people assessed support needs.

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.

People told us that the provider lift PPE at their home for staff to use when supporting them with personal care. One person said, “Staff have PPE which the manager brings and leaves them for staff to us”.

Staff told us they had access to hand gel and PPE, including aprons and gloves, and were expected to use these in line with guidance. Procedures supported a timely and coordinated response to infection outbreaks. Training records showed staff had completed infection prevention and control training. The registered manager said, “I ensure all PPE in place for staff to have access at any time”.

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.

We reviewed people’s medicines administration records (MARs). Records were complete and clearly documented, providing assurance that medicines were administered and recorded in line with the provider’s procedures.

At the time of our assessment, it was identified that people’s PRN guidelines had not been signed by the GP. However, the registered manager sent us evidence confirming that they had asked the GP to review and sign the guidelines.

Staff told us they felt they were given the right training and support be able to administer medicines to people they supported. One staff said, “I been given the right training to do my job safely”.