Otto Schiff

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. Leaders used learning to identify and embed good practice.

The care manager investigated incidents and followed these up, for example by contacting hospital staff after a person experienced a fall. The provider collated all incidents and reviewed them daily, with further analysis undertaken monthly and quarterly to identify trends and patterns. The provider shared learning through care manager forums, team meetings and handovers to support improvements in practice, and staff were able to describe how learning was applied in their roles.

The provider also shared learning with people and their relatives, including where investigations had taken place, and discussed themes at residents’ and relatives’ meetings. In addition, the provider undertook reflective learning following people’s deaths to identify improvements and support ongoing learning across the team. This approach supported continuous improvement in safety practices and reduced the risk of repeated incidents.

Relatives described how staff recognised and responded to changes in people’s condition promptly. One relative told us, “Staff spotted the signs and responded very quickly”, showing concerns were acted on without delay.

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 provider worked effectively with GPs, district nurses and specialists to support people’s ongoing needs. Staff escalated concerns to senior staff and external professionals. One staff member told us, “When we see something unusual not daily routine, we inform team leader to assess and check.” Records showed that staff made referrals appropriately, for example in response to changes in people’s health or swallowing needs.

Staff monitored changes in people’s health and communicated with professionals and families to ensure care remained appropriate.

Staff used handovers and electronic care records to support communication and coordination, which helped them understand people’s needs and provide consistent 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.

Staff recognised safeguarding concerns promptly and recorded them appropriately and clearly documented outcomes. The provider’s central safeguarding team and designated safeguarding lead provided effective oversight and support. The care manager undertook initial investigations and made referrals to external agencies. The provider shared learning from safeguarding outcomes with staff to support improvements in practice, supported by regular training. A care worker told us, “I would talk first to my team leader, raise a concern,” and confirmed there were clear escalation routes, including access to a designated safeguarding contact. Where people were subject to Deprivation of Liberty Safeguards (DoLS), the provider ensured appropriate authorisations were in place and reviewed.

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.

Care plans reflected people’s individual needs, preferences and risks, including their health, mobility, nutrition and cultural requirements. Staff understood people well and described how they adapted care based on changes in people’s condition, including recognising non-verbal signs such as pain or distress. The care manager told us, “When it comes to being in pain, body language, facial expression…even if they can’t talk you can determine that they need something.”

Staff helped people maintain independence while managing risks, for example by assisting with eating at an appropriate pace and supporting safe mobility. The provider involved people and their representatives in care planning and reviews and worked with professionals to support risk management.

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

Staff maintained a clean, bright and well‑organised environment that was free from hazards. The provider designed the environment to meet the needs of people living with dementia, including personalised bedrooms with photographs and memory boxes outside rooms to support orientation and reassurance. We observed housekeeping staff actively cleaning throughout the service, and good standards of hygiene supported infection prevention and control.

The provider ensured that adaptations met people’s needs, including the safe use of equipment such as beds with rails where appropriate. Staff maintained flooring and communal areas in good condition to reduce risks, and carried out regular checks to ensure people’s safety, including monitoring at night. The provider implemented enhanced security arrangements in response to identified risks, including 24 hour staffing, controlled access, collaboration with external agencies and ongoing risk assessment.
 

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.

Staff had the skills to deliver effective care, with high compliance in training deemed mandatory and regular refreshers, including safeguarding, moving and handling and medicines competency. Staff accessed training through an electronic system and described feeling confident in their roles. The provider supported staff through regular supervision, and communication systems such as daily handovers and electronic care records helped staff understand people’s needs and work together effectively. The provider followed safe recruitment processes and maintained a stable staff team, which supported continuity and positive relationships with people using the service.

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.

Staff maintained a clean and hygienic environment, and we observed housekeeping staff actively cleaning throughout the service. The provider maintained an environment free from odours and visibly well maintained, which supported infection prevention and control. Staff completed infection prevention and control training, and records showed regular updates to maintain knowledge and skills.

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.

The provider managed medicines safely, and we found no gaps or omissions in medicine administration records. Staff followed clear protocols for administering medicines, including ‘when required’ medicines, which were regularly reviewed by GPs. Staff followed appropriate processes for covert medicines, with clear documentation and authorisation from relevant professionals.

The provider checked and recorded medicines stock accurately, including monitored dosage systems and loose medications, and staff demonstrated appropriate competency in medicines management, with regular competency assessments and training updates. GPs were involved in reviewing and adjusting medicines to ensure they met people’s needs.

We identified minor areas for improvement in medicines recording, including ensuring consistent documentation of controlled drug checks and updating a medication record, which the provider acknowledged. These did not impact on the safe administration of medicines.