Elysium Care Partnerships Limited - 1 Lichfield 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 changed to 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. Lessons were learnt to continually identify and embed good practice.

There was a learning culture and focus on safety at the service. The registered manager and the staff team regularly met to discuss improvements at the service, and to people’s care and support. For example, following the identification of shortfalls, staff received training to increase their confidence and competence around the recording and reporting of incidents. Incidents were collectively reviewed, and learning was shared through team meetings, handovers and supervision. One member of staff told us, “We changed the culture about how to raise concerns. We now perceive this [sharing concerns] as a positive thing.”

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.

People safely transitioned into the service. People’s needs, risks and preferences were assessed before they received a service. This was to ensure the provider could safely meet people’s needs. Where required, referrals were made to health and social care professionals to carry out specialist assessments. These were reflected in care plans which provided staff with guidance on meeting people’s needs. The registered manager monitored people’s health and access to services to ensure they were safely and effectively supported.

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 were safe and protected from abuse and improper care. One relative told us that, “Overall [family member] does seem happy at the care home.” Staff received training to identify and report any concerns they had about people’s safety and welfare. Concerns were reported appropriately to the local authority and the service engaged with subsequent investigations. Safeguarding incidents were monitored and reviewed by the provider. This meant that lessons learnt were shared across the organisation. Where actions were required, the provider carried out checks at the service to confirm they had been satisfactorily and safely completed. The registered manager continually reviewed accidents, incidents, near misses and people’s satisfaction to ensure that any safeguarding concerns were identified and acted upon in a timely manner.

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.

People were protected against the risk of avoidable harm. Staff assessed people’s risks and plans were in place to mitigate them. For example, when people presented with behavioural support needs, staff were trained to reduce and manage them, and care records reflected how this should be done safely, sensitively and in a person-centred way. Where people were at risk of swallowing unsafely, staff had clear guidance around food consistencies and the support people required. This meant that where risks were foreseeable, action was taken to decrease them.

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

At our last inspection we found that some improvements were needed to the décor, design and adaptation of the environment. At this inspection were found that improvements had been made and further required redecoration was planned. People and their relatives were involved in selecting the décor at the service, and people’s bedrooms were personalised.

The registered manager and deputy manager oversaw a programme of checks to ensure the environment was safe. These included health and safety, fire safety and food safety checks. Where actions were required, these were recorded, planned and completed. Window restrictors were in place in people’s rooms and throughout the service to prevent people falling from height.

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 received their care and support from staff who were recruited through robust processes. New staff were recruited following application and interview processes and the provider carried out a range of background checks. New staff received an induction to enable them to perform their role effectively. One member of staff explained their induction experience to us, “You shadow when you start. You read files, and you get to know people over time.”

People were supported by skilled and knowledgeable staff. Staff received training in areas that included health and safety, first aid, communication and behavioural support needs. Staff knowledge from training was tested shortly afterwards to confirm their learning.

The registered manager and deputy manager supported staff with regular one to one supervision meetings at which people’s care and support and their personal development was discussed. One member of staff told us, “We can say what we want, and they [managers] say what’s expected of us. It’s encouraging. We talk about residents, and they give me some more ideas.”

People were supported by staff whose performance was evaluated. Staff received annual appraisals at which their roles and how they performed them were discussed. Appraisals were also used to identify training and development for individual staff team members.

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.

People were protected from the risk and spread of infection. A programme was in place for the regular cleaning of high contact points such as work surfaces, taps and door handles, as well as the thorough cleaning of the service. A member of staff was designated the role of Infection Prevention and Control (IPC) lead. They conducted regular IPC audits which were reviewed by service management. Similarly other staff had responsibility for the control of potentially harmful cleaning substances; the clinical area; and the cleanliness of the care home’s vehicle. Their observations, checks and actions were recorded and reviewed.

There were sufficient stocks of personal protective equipment for staff such as gloves and aprons. Staff received training in infection prevention and control, controlling potentially hazardous substances and food safety. Good hygiene practices meant people were protected against infection risks.

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.

At our last inspection we found that some medicines had passed their expiry dates and medicines administration record (MAR) charts had not always been completed. This failure to safely manage medicines was a breach of Regulation 12 of the Health and Social Care Act. At this inspection we found that all medicines were in date and MAR charts were completed appropriately. This meant the provider was no longer in breach of regulation 12.

People received their medicines safely from staff who were trained to administer them. Medicines were stored securely, and people’s photographs were displayed within the medicine cabinet. This helped to ensure the right people received the right medicine.

Where people received ‘when required’ medicines, records stated clearly when they should be administered and the maximum number of doses permissible in a 24-hour period. Where people were prescribed creams, body maps were in place illustrating exactly where they should be applied. Medicines stocks were regularly checked and the correct balances confirmed. Medicines records were audited by the registered manager to confirm they had been completed correctly.

In line with good practice, people were supported with regular reviews of their medicines. This was undertaken with healthcare professionals and focused on reducing, where appropriate, the medicines people were prescribed.