Creative Support – Hall Lane

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 remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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. The service listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Where incidents had increased, we saw evidence of multi-disciplinary working with social workers and health professionals to ensure people were kept safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed. However, one health care professional told us “Information was not always up to date and not always accurate. An advocate has fed back that sometimes it’s difficult to get incident reports, care plans, daily notes. They do eventually but it takes time. Sometimes it’s difficult to get answers following appointments.”

There was continuity of care, including when people moved between different services. For example, one person’s incidents had increased, so the service worked in collaboration with other health professionals to manage their needs whilst they waited for a more suitable environment. During this time staff supported the person along with staff from their new home and supported a smooth transition. The family member had thanked the team for their support which helped to manage the service users’ risks safely whilst at Hall Lane.

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. There was a safeguarding policy in place which had been followed and staff received training. Staff were knowledgeable about the types of abuse and knew who to report any concerns to. One staff member said, “I would report to the manager straight away about any concerns. If I report it and nothing is done, I will follow the policy and take it further.” One relative told us, “I think [Name] is very safe.”

The provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, the records of risks were not always completed or up to date. For example, one person had a catheter and there was no information on their risk assessment to indicate how staff should mitigate potential risks of infection. Following our feedback on day one of the inspection this was updated. Two people’s positive behavioural plans were not up to date as they did not reflect the current incidents which had taken place.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People’s care plans included information for staff regarding potential environmental risks, such as fire checks.

The provider made sure there were enough qualified, skilled and experienced staff, who received regular supervision and development. However, some staff told us they did not feel supported and that there were poor relationships between staff and management. The management team acknowledged this and were considering ways in which this could be improved. Staff worked together well to provide safe care that met people’s individual needs. One person said, “Yes, there are enough staff. We were short staffed last year so sometimes get agency staff, but no more.” Staff undertook regular training to keep their knowledge up to date. The processes for recruitment of staff were safely managed. The provider had clear records to show the interview process, reference requests and use of the Disclosure and Barring System (DBS).

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 had undertaken infection prevention and control training and were provided with personal protective equipment (PPE).

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. For example, one person received their medicines covertly however, there had not been any documentation obtained from a medical professional to indicate that this would not have any contradictions taking the medicine in this way. Following our feedback the provider took immediate action to resolve this. Medication audits were not always robust as they did not include information about covert medicines which could have identified the issues found. The audits we reviewed had actions which had not been completed in a two-month period. As required medicines were administered however, we found one person had been administered medication in the morning when it was prescribed to be given at night. We fed this back to the provider who took immediate actions to resolve these issues.