Elysium Care Partnerships Limited - 13 Alexandra Gardens

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.

The last rating for this key question was good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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 systems to help learn when things went wrong. However, some relatives told us they were not informed about incidents when these happened. We discussed this with the management team. They agreed to review how and when relatives were contacted to ensure they had explanations of what had happened and were included in planning improvements to the service.

Staff reported and recorded all accidents, incidents and concerns. Managers at the service and senior managers reviewed these and used the information to help plan people’s care. Staff told us they discussed lessons learnt with managers and each other. We saw care plans and risk assessments had been updated to reflect learning. This helped to ensure staff provided consistent support which reduced the risks of these incidents reoccurring.

The provider had systems to ensure safe transitions and pathways. Everyone living at the service had lived there for many years.

Staff kept clear records about people’s needs, including how they communicated. These were shared with other professionals when people accessed external services. Staff escorted people on all appointments and acted as advocates when liaising with healthcare professionals.

The provider had systems designed to safeguard people from the risk of abuse. Staff undertook training about how to recognise and report abuse. Staff were able to explain about this. The provider worked with the local safeguarding authority to report and investigate allegations to help protect people from avoidable harm.

The provider requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. Decisions about people’s care were made in their best interests and for their safety.

The provider carried out regular reviews of all restrictive practices. A team of managers, including those who did not work at the service, assessed these to make sure people were being supported in the least restrictive way and alternatives were considered. Managers used examples of best practice from other services to help with this work.

Staff worked with other professionals to assess risks to people’s safety and wellbeing. They created personalised plans to help mitigate risks. Staff worked with people and their families to help them understand about positive risk taking.

Some people expressed themselves in ways which could challenge the service. Staff worked with specialist professionals to develop person-centred plans which set out structured interventions to help reduce people’s anxiety and agitation. Staff undertook training and had guidance to ensure they could respond appropriately to any physical challenges without people being harmed.

Whilst the environment was suitable to meet people’s needs, some areas needed renovation or repair. Old, broken furniture and equipment was stored in the garden awaiting removal. The sensory room was also used as a storage area which detracted from the intended use. Damaged walls and equipment needed repair.

Some relatives told us that maintenance could be improved. However, comments from others included, “The home is clean, well maintained and the garden is nice.” People had personalised their rooms.

A fire risk assessment stated areas of improvement were needed. A manager told us the provider had made the required safety improvements. Following our visit to the service, they sent us evidence of this. An external company had reassessed the fire safety of the building.

The provider deployed enough staff to meet people’s needs and keep them safe. There was an established staff team. Staff absences were covered by the provider’s own permanent staff. Most of the staff had worked at the service for several years. They knew people well and were able to tell us about people’s individual needs and how these were met. Relatives told us they thought there were enough staff. Their comments included, “I believe there are sufficient staff.”

The provider had systems to ensure safe recruitment of staff. These included checks on their suitability, knowledge and skills. Managers carried out regular assessments of staff competencies. Staff completed a range of training relevant to their role. Staff had regular opportunities to meet with a manager to discuss their work and personal objectives.

The environment was clean and well maintained. Staff undertook training to understand about infection prevention and control. There was a schedule of cleaning tasks for the service. Staff were provided with personal protective equipment (PPE) to wear when needed. Staff and managers carried out audits of cleanliness and infection control. Relatives told us they were happy with the cleanliness of the home. A relative commented, “The home appears to be cleaned well.”

People received their medicines safely and as prescribed. However, some of the procedures for storing and recording medicines had not been followed. For example, medicines which were no longer in use had not been returned to the pharmacy for disposal and the labels of some medicated creams had become worn and were unclear. We discussed this with the management team, and they agreed to address this.

Staff worked with prescribing doctors to ensure people’s medicines needs were met. They supported people to reduce medicines when appropriate in line with the principles of “Stopping over medication of people with a learning disability and autistic people (STOMP)”. This is national programme to stop the inappropriate prescribing of psychotropic medications.

Staff undertook training to understand about safe medicines management. Managers conducted regular audits to check medicines systems. Staff kept accurate and clear records to show when medicines were administered. People, who had the capacity to understand, were given information about their medicines and supported to understand why they were prescribed these.