3L Care Limited

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 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 69 (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 was building 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. We found evidence of learning and improvement in clinical areas. The provider carried out reviews following any incidents to understand what went wrong. Staff involved were asked to reflect on what happened, and their skills were reassessed to make sure they were competent. The provider had moved away from simply reacting to incidents and was focusing on learning from them and preventing them happening again. Staff described a reflective approach to safety. They felt supported to learn from mistakes rather than blamed for them. One staff member said, “Reflection is expected now, not blame.”  

The provider made sure there was continuity of care, including when people moved between different services such as hospital admissions and discharge. People’s care plans showed regular involvement from a wide range of health professionals. Care planning was joined up across services. Professional partners told us staff attended discharge planning and best interest meetings to support consistent and safe care. The provider maintained a clinical risk register which identified risks. It listed risks, scored how likely and how serious they were, named who was responsible for each one, and was reviewed regularly. Risk assessments covered complex health needs such as seizure conditions, swallowing difficulties, and behaviour that may cause distress. Hospital passports were used to share important information about people’s needs during hospital admissions. One relative told us, “Staff kept in contact every day,” when their loved one was in hospital. Care records clearly described risks and showed consistent use of risk assessment tools to support safe and effective 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. They had ensured systems became stronger and more transparent. There had previously been serious concerns, including allegations of harm and a closed culture. The provider had appropriately reported incidents to the Local Authority and the Care Quality Commission (CQC), and where necessary, they had conducted investigations and taken appropriate actions. People were supported to develop safety awareness and recognise signs of abuse. One person told us, “I feel safe here.” When people had raised any concerns or worries, the provider always took these seriously and formally recorded and reviewed them. Staff understood safeguarding procedures, including when and how to raise concerns, and how whistleblowing works. One staff member said, “If it’s not acted on internally, we go higher.” Relatives told us they felt more reassured and described improved transparency. One relative told us, “Before, I didn’t feel [Name] was safe. Now I do.” Another relative stated, “[Home Manager] doesn’t hide anything. She is constantly updating us.” 

The provider worked 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. Leaders told us that, in the past, the service was very cautious about taking any risks. They had been working to change this by working more closely with other agencies and services. Staff were trying to balance keeping people safe with respecting their independence. They encouraged positive risk-taking and supporting people to lead fulfilling lives. For example, they helped people safely access the community and manage money.  Care plans showed staff understood people well, including how they communicate, what might trigger distress, and what sensory needs they have. People’s positive behaviour plans explained why certain behaviours might happen and gave clear steps on how to prevent them and what to do if they occur. Equipment was adapted for each person to help them be as independent as possible and to keep them safe. This included specialist wheelchairs, supports to help with positioning, and aids to reduce risks such as burns or choking. Staff we spoke with told us they support people to make their own choices wherever possible. One member of staff said, “It’s about the individual’s preferences, not what we are going to do.” People were involved in everyday decisions about their lives, and relatives said they now feel more included in discussions about risks under the current management team. One relative said, “We have meetings about how we can improve [Name]’s life.” 

The provider did not always detect and control potential risks in the care environment. Environmental checks and audit systems were not working as reliably as they should. Standards of maintenance were not consistent throughout the building. We found several concerns, including damaged flooring and cracked fixtures. Some areas, including the boiler room, were not securely locked. However, the provider responded quickly to our concerns. Some people and relatives raised concerns about environmental instability. One relative said, “Lifts keep breaking and hoists keep breaking.” One person told us, “They need a new lift. It keeps breaking.” However, the provider had systems in place to mitigate risks, including access to alternative equipment where required, and required safety certification was up to date. The provider had addressed previously identified fire safety issues. We did not find evidence people were unable to receive care because of equipment issues. People and relatives had been consulted about the environment to ensure adaptations and reasonable adjustments were going to meet people’s individual needs. One member of staff said, “Money is being put back into the home.” The required building safety certificates were all up to date. 

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. Staffing levels aligned with commissioned hours, and rotas were managed to avoid gaps. The provider’s recruitment processes were safe and thorough, and included scenario-based interview questions, probation periods for new staff, and structured shadow shifts where new staff work alongside experienced colleagues before working independently. Staff received regular supervision. We observed staff communicated calmly and clearly during a shift handover. Staff feedback was mostly positive, and they told us morale has improved. One staff member said, “They offer so much more training now,” and another said, “Since the new manager came, we feel supported.” Where poor performance had been identified, appropriate action had been taken. Some relatives we spoke with described past cultural issues, including cliques among staff and inconsistencies between day and night shifts. They told us this had improved under the new management team. We found staffing levels were generally sufficient. One person said they would prefer fewer agency staff working at night. 

 The provider had systems in place to assess and manage the risk of infection. However, these were not always followed consistently in practice, and standards of infection prevention and control were not always maintained. We found cleanliness concerns, including unclean fridges, and cupboards. There were dirty surfaces, cooking equipment and overflowing bins. Waste was not always being separated and disposed of correctly. There were unpleasant odours from clinical waste bins. We found mould in some bathrooms. Some furnishings and equipment were dirty. Hand hygiene was not always consistently followed by some staff. We found one person had received personal care on another person’s bed, which was not appropriate practice. A relative told us, “More infection control could be implemented, like handwashing, and aprons.” Even though cleaning schedules, health and safety plans, and infection control training were in place, the number and types of issues we found showed these checks were not always being followed in everyday practice. Improvement was visible on our second visit, showing the providers responsiveness to concerns. Staff received infection control training during induction and ongoing e-learning. They were able to explain infection control procedures appropriately and understood their responsibilities, including ensuring personal protective equipment (PPE) supplies, cleaning high-touch surfaces, and wearing new PPE for each person. People said staff supported them well to keep clean and maintain good personal hygiene. People told us their bedrooms were kept clean and tidy.

The provider had made improvements to ensure medicines and treatments were safe and met people’s needs, capacities and preferences. Medication governance had strengthened, and there was evidence of learning from previous incidents. Earlier medication errors had been appropriately reported, investigated and reviewed, with actions taken to reduce the risk of recurrence. Improvements included the introduction of protected medication times, strengthened MAR processes, use of lockable transport bags for controlled drugs and the implementation of an electronic medicines administration system to improve oversight and accuracy. The provider had introduced enhanced monitoring systems for high-risk medicines, including alerts for contraindications and structured follow-up processes to monitor for side effects. This supported staff to identify and respond promptly to potential risks. Audit records showed protocols had been updated and staff were informed of changes. Relatives reported improved communication and transparency. Medicines records demonstrated prescriptions were regularly reviewed, including adjustments to pain relief, clear instructions for rescue medicines and updates following changes in people’s health needs.