19 Leicester Villas

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. This is the first assessment of the service under the current provider. This key question has been rated 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 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. Staff raised safety concerns with managers, and learning and changes were shared through staff meetings and the communication book. Relatives also felt able to raise concerns and said they were kept informed when incidents occurred. There was some inconsistency in staff understanding of the provider's incident recording arrangements. One staff member said, “I wouldn’t even know where to find an incident report form, I just let [registered manager] know.” However, staff knew who to raise concerns with and we found incidents were reported to managers, with learning and changes shared with staff. We found no evidence that this had resulted in incidents being missed or concerns not being acted on.

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 registered manager reviewed referrals with families and social workers to establish whether the service could meet a person’s needs and whether these were compatible with people already living there. Planned visits, social stories and photographs helped people become familiar with the home before moving in. Hospital passports were available containing information about people’s health, communication and support needs. These arrangements helped people prepare for changes and supported other services to understand how to care for them.

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 appeared comfortable with staff and one person indicated they felt safe when asked using communication suited to their needs. Staff understood how to recognise, report and escalate concerns. Relatives also felt confident raising concerns. The provider worked with the local authority to respond to safeguarding concerns and enquiries. We reviewed Deprivation of Liberty Safeguards (DoLS) authorisations, which provide legal authority for care arrangements that restrict people’s freedom. One authorisation required restrictions within the home to be reviewed. Written guidance instructed staff to restrict access through an internal door only in specific circumstances and to reopen it afterwards. This helped staff understand the limits of the restriction and avoid its unnecessary use.

The provider did not always work effectively with people to understand and manage risks. Although care generally supported people's independence, known risks were not always fully assessed or reflected in people's care plans. One person had a history of falls and could become very unsteady or faint when unwell. At our first visit, no specific falls risk assessment was available and their care plan had not been updated following the latest fall. This meant the provider could not demonstrate that staff had current, consistent guidance to reduce the risk of further falls and respond safely when the person's risk increased. The registered manager responded promptly. During the assessment, a falls assessment and updated care guidance were completed. These included measures for staff to follow when the person was unwell and at increased risk of falling. Other records demonstrated a more positive approach to managing risk. For example, one person was supported to prepare hot drinks with staff supervision, enabling them to maintain independence while managing the risk of scalding.

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 home was clean and tidy. Emergency grab folders containing evacuation information were available at exits to help staff support people in a fire. Following an earlier ceiling collapse in the ground-floor bathroom, the registered manager had taken action to make the area safe while further repairs were arranged.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. The provider was recruiting to three full-time vacancies and the service relied on agency cover, with regular agency workers used where possible to provide familiarity and continuity for people. However, staff consistently described pressures associated with the vacancies and felt more permanent staff were needed. One said, “It would be nicer to have permanent, consistent staff members in every shift.” Staff reported occasions when they worked alone and had to prioritise urgent needs. Another staff member described evening outings not taking place because of lone working. These pressures limited some opportunities for people to access their community and reduced the time available for staff training and administration duties.

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. The service was clean and well maintained. Staff had access to personal protective equipment such as gloves and aprons and were aware when to use them. A cleaning schedule was in place for staff to follow and people were encouraged to develop their independence by taking part in maintaining their environment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. At our first visit, most staff administering medicines did not have current competency assessments, as required by the provider’s policy. This reduced assurance that staff had maintained the skills needed to administer medicines safely. The registered manager told us staff would not administer medicines until they had received appropriate training and their competency had been assessed. At our second visit, we reviewed competency records and found most assessments had been completed, although some remained outstanding. Some protocols for medicines used when needed, known as PRN medicines, were overdue for review. The registered manager updated the PRN protocols and addressed recording requirements with staff during the assessment. Records for regular oral medicines were complete, and the registered manager and deputy manager carried out routine stock checks.