55 Sandwich Road

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.

There was a positive culture embedded within the service, where learning was actively sought and any safety incidents were closely monitored and analysed to improve people’s care. Management regularly reviewed incidents and had recently undertaken focused training sessions with staff to ensure they had a consistent understanding of which incidents needed reporting. When incidents did occur, the provider acted with candour to notify people’s representatives as well as the local authority and CQC in line with their statutory responsibilities. There was a robust system to monitor incidents to understand any contributing factors or if they represented an unmet support needed. There was a commitment to using incidents as an opportunity to learn, and these were discussed at staff meetings. One staff member told us “If there are any incidents I would report them to management. We discuss them as a team and on handover between shifts. There is always room for improvement.”

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.

There were clear systems setting out at what point the provider might need to make a referral to health and care partners in response to people’s changing needs. There was robust guidance setting out signs of concern that would require specialist oversight, as well as regular monitoring of people’s care to proactively identify if they needed additional support in managing their wellbeing. One person’s needs had changed and a referral was made to a specialist service. We heard positive feedback about how staff had monitored this and been responsive once concerns were identified. People had hospital passports which would guide other health professionals involved on how to communicate with them in way that respected any sensory needs or adaptions, to help people access health appointments.

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.

Staff were knowledgeable about their responsibilities to protect people from the risk of abuse or neglect and spoke confidently about what they would do if they were concerned that might be happening. One staff member told us, “I would be vigilant of any unexplained marks, or changes in people’s behaviour around certain staff or rooms. I would report any concerns to management, but I also have our whistleblowing policy if I was worried things were not being addressed.” Although neither person being supported could communicate verbally, staff could clearly describe how they would monitor their facial expressions and body language to monitor their wellbeing and when something might not be right. There was clear guidance on what factors meant people were at greater risk of abuse including what steps staff and the provider needed to take to protect people.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where the risks to people were deemed sufficient that restrictions such as living in locked accommodation were needed, to ensure their safety, appropriate authorisations were sought and recorded.

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.

There were clear and robust plans in place setting out how the provider would work together with people to manage risks safely and protect them from avoidable harm. These were regularly reviewed to ensure they remained up to date and represented people’s current needs. For example, one person was at a risk of seizures and staff had clear step by step guidance on how they should respond if this happened and had also received specific training in these areas. Where people had a greater risk of choking, staff ensured people received an appropriate diet in line with clinical recommendations to reduce this risk. Staff were guided to encourage people to eat slowly and be on hand to observe people whilst eating, which we identified was the case during our inspection.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Although the premises was largely well maintained, there were some areas of risk which needed to be addressed to ensure it was always a safe environment. For example, ensuring hazardous cleaning chemicals were always stored securely. A recent fire inspection had identified some areas where improvement was needed to the safety of the building, however the provider had put an action plan in place and were working to ensure these areas were addressed in a timely manner. Monitoring of water temperatures was also inconsistent and staff had been recording temperatures that were in excess of safe levels. Although we found that the temperatures of water were not at an unsafe level, management had not previously identified or responded to the high temperatures that were being recorded in error. When we identified issues, management took prompt action to mitigate these risks.

The building was vibrant and pleasant space that was personalised to the needs and preferences of people. This included a large garden space which people enjoyed spending time in and maintaining, as well as a lounge decorated in photographs of activities people had undertaken with their staff team. There were systems of regular checks to ensure the safety of utilities such as gas and electricity, and routine fire drills and checks of fire safety equipment were undertaken.

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.

People were supported by a staff team who had worked with them for many years and knew them exceptionally well. Staff had received training to allow them to support people’s needs including around learning disabilities and autism. Their knowledge and competency were checked through regular supervisions and appraisals, and in order to undertake higher risk tasks such as administering medication. There were systems in place to ensure that staffing levels remained appropriate to people’s needs, and to ensure that staff working patterns remained safe. When staff were recruited, appropriate checks were undertaken to ensure they were safe to provide care and support to people.

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.

There was a high overall standard of cleanliness at the service. Where possible, people were actively encouraged to be part of keeping their own space clean including supporting with keeping their room tidy or with laundry. Staff were trained and knowledgeable about how they would protect people from the risk of infection. There were a small number of areas where greater attention with cleanliness was needed, and checks by the provider had not identified. Once raised these issues were promptly addressed.

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.

There were robust systems in place to ensure that people received the medication they needed, when they needed it. Where people were prescribed medication, documents clearly set out how this should be given and there were clear records monitoring when it had been given. Medication was administered by staff who were trained as competent to do so safely. There was a system of regular checks to ensure people’s medications were being managed and stored safely, and that people had enough supplies available. If errors were made then appropriate learning was taken, and staff members would undertake further learning and checks before they could support with medication again.