Delrose

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 requires improvement. At this assessment, the rating has changed to 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.

Improvements had been made following our previous inspection. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events.

Lessons were learnt to continually identify and embed good practice. Staff knew what incidents to report and how to report them. The manager shared learning with staff through staff communication channels and team meetings.

The manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

Improvements had been made following our previous inspection. 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.

The provider had a robust admissions policy in place. The manager was able to explain the process which included assessing people to establish suitability and compatibility prior to moving in, visits for the person to the home, and allocating a keyworker to the person who would lead on the process and provide additional continuity for them.

People were consistently supported when they were distressed and there was a focus on planning for a good day and understanding what had caused people distress so positive changes could happen.

Improvements had been made following our previous inspection. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The service shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies. Where restrictive practices were in place Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions placed on people to keep them safe.

Improvements had been made following our previous inspection. The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. For example, people were assessed for risks of falls, risk of choking and risks related to medical conditions. When risk had been identified staff acted to keep people safe such as using specialist equipment to monitor their health condition.

The manager told us about a person’s health condition which had been restricting the frequency the person could go out. The manager collaborated with them, their relatives and health professionals and trialled a solution which was successful, meaning the person was able to go out more frequently.

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

Health and safety and fire safety risk assessments were completed and checks made of equipment to ensure it was safe to use. During our inspection we observed several fire doors which did not close properly. The provider was aware of these concerns and had reported them. The fire doors were repaired during our inspection.

Improvements had been made following our previous inspection. The service 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.

Relatives told us there had been a big improvement in staffing over the past 12 months and they felt staff knew their relatives well.

The manager had a training matrix in place which evidenced most staff had completed all of their statutory and mandatory training and competency assessments to ensure they were able to meet people's individual needs. The provider ensured staff attended bespoke training relating to supporting people with a learning disability and autistic people. Where staff had not completed training, they were booked onto a session. The provider followed safe recruitment practices.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We observed some bedrooms with paint missing on areas of the walls. We observed woodwork which was scuffed and chipped. We spoke with the provider about this. They showed us a schedule of works where these concerns had been highlighted by the manager and were waiting to be completed.

In the kitchen, we found food was not always managed in accordance with good practice increasing the risk of contamination. We spoke with the provider about our concerns, they removed the food and told us they would put robust systems in place to mitigate the risk of this happening again.

Relatives told us the home was clean, and this was an area of improvement. We observed the home was mostly clean.

Improvements had been made following our previous inspection. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

Staff received medication training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines. Staff told us they felt well trained and confident to support people to receive their medicines safely. Staff supported and involved people to manage their medicines and followed best practice guidance for administering medicines. The staff team were proactive at reporting any changes to people’s medicines promptly.

The manager told us, during people’s annual health reviews, stopping over medication of people with a learning disability and/or autism (STOMP) plans were reviewed. They also shared with us examples of where recent medicines reductions had been made.