Outreach Office

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 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.

The servicedemonstrateda positive learning culture. Theregisteredmanager explainedanddemonstratedthrough recordsthat accidents, incidents, complaints, and concerns were reviewed monthly toidentifytrends, contributing factors, and learning opportunities.People and their relatives told us they wereregularly askedfor feedback about the care provided and felt confident raising concerns. Staff also reported that concerns were listened to and acted upon, with one staff memberstating, “We do raiseconcernswhen we have them and we do get listened to.”

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.

Pre-admission assessments were completed before people moved into the service. Staff described receiving handovers and reviewing care plans before supporting people. Care recordscontaineddetailed information about preferences, personalhistoryand support requirements, supporting continuity of care.

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 consistently told us they felt safe. Comments included“IFeel very safe. Staff treat us very well” and “There is no concern oversafety.”Safeguarding safety”.Safeguardingtraining had been completed and staff understood reporting procedures.Theregisteredmanager stated they completed daily walk-rounds and would escalate any concerns.

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.

Risk assessments covered mobility, communication,wellbeingand hydration. Mobility plans detailed the use of mobility aids, environmentaladaptationsand staff responsibilities.

One person told us, “I am very independent though, I just have support where I need it.” Staff explained care plans werepersonalisedand reflected individual choices. Families and professionals were involved whererequired.

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 environment wasobservedto be clean,safeand wellmaintained. Apartments reflected personal preferences and supported independence through adaptations and mobility equipment. One person told us, “Staff knock on the door when they come in.”

Communal areas and the garden were accessible and free from hazards.

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.

While some staff reported the use of agency workers to supportstaffing during periods of vacancy, management staffing, managementwere actively recruiting tomaintainworkforce stabilityand fill vacancies.

Robust training, recruitment, and competency assessment systems were in place to support staff in delivering safe and effective care. Staff spoke positively about the training provided and described feeling confident in their roles. One member of staff explained, “Training has enabled me to do CPR (cardiopulmonary resuscitation).” Relatives identified consistency of staffing as a key strength of the service. One person told us, “The staff are wonderful.”

Observations of moving and handling practices demonstrated safe care delivery, with staff communicating respectfully, providing reassurance, and maintaining people's dignity throughout.

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.

Infection prevention and control (IPC) systems were embedded within daily practice. People consistently reported that staff used personal protective equipment (PPE) appropriately to reduce the risk of infection. One person told us, “All [staff] wear PPE, gloves and aprons where needed.”

Staff demonstrated a good understanding of their responsibilities in relation to PPE use, safe waste disposal, and infection prevention and control procedures. Observations and discussions with staff indicated that infection control practices were applied consistently to help maintain a safe and hygienic environment for people receiving care.

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 managed medicines safely, with appropriate care plans, risk assessments and PRN protocols in place to support administration. Staff received medicines training; however, competency assessments for 3 of the 4 staff reviewed required updating to ensure continued compliance with the provider’s procedures. This was discussed with the manager.

Monthly medication audits were completed, and no medication administration errors were identified during the inspection period. Feedback from a relative also provided reassurance that staff were receiving appropriate training and assessment in medicines management.