Senad Community Ltd-Coventry

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 outstanding. At this assessment the rating has remained outstanding.
 

This service scored 88 (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 strong, proactive and positive culture of safety based on openness and honesty. Staff and leaders listened to concerns about safety, investigated incidents thoroughly and reported safety events appropriately. Leaders consistently used learning to identify and embed good practice.

The provider used incidents, safeguarding activity, audits, staff feedback and supervision to identify learning and improve safety. Leaders analysed safeguarding activity across the year and shared findings with operations teams across the East and West Midlands. This helped leaders identify themes, strengthen practice and make changes across the wider service.

Leaders identified medicines as a key area of learning. They recognised that, despite established training and competency checks, human error remained a factor in some medicine incidents. In response, the provider used reflective group meetings with staff following medicines incidents. Leaders also updated procedures and strengthened oversight arrangements. This showed the provider did not respond to incidents in isolation but used themes to improve systems and staff practice.

Staff described an open and accountable culture which enabled them to feel confident and supported to report any issues when things went wrong. One staff member told us they reported a medicine error shortly after completing training and competency assessment. The provider arranged further training and reassessed their competency before they returned to medicines administration. Another staff member told us, “Incidents are followed up through team meetings and emails, and managers ask staff how similar incidents could be prevented.” Another staff member said, “Lessons are definitely learned here and we take accountability.”

The provider used electronic systems to analyse incident themes, including dates, times, locations, staff involvement and the duration of incidents. Leaders also used staff forums, emails, read receipts, supervision, observations and spot checks to share learning and check staff understood changes. A real-time Notify system alerted directors, quality and compliance staff to notifiable incidents. Senior leaders reviewed an overarching tracker to monitor themes, identify whether training needed to change and check that incidents were followed through.

Learning had a positive impact on safety which improved escalation of concerns and reduced the risk of staff making decisions in isolation. This meant people benefited from quicker action, shared decision-making and safer responses when risks changed.

One example showed how the provider used learning to make a significant difference to a person’s safety, wellbeing and quality of life. The person had experienced repeated incidents of distress, which staff recognised as the person communicating an unmet need rather than an incident of distress in isolation. Leaders reviewed all relevant audits, incident records and staff observations related to the person. This helped them identify trauma-related behaviour patterns, sensory triggers and communication needs. The provider used this learning to redesign the person’s support with the assistance of staff and professionals. In addition to updating the persons care plan after incidents, leaders changed the approach, so staff focused on preventing distress before it escalated, reducing sensory triggers, providing trauma-informed reassurance and responding earlier to subtle changes in the person’s presentation.

This went beyond responding to individual incidents. The provider used learning to understand why distress was happening and changed the person’s support to prevent distress escalating. The providers records showed this led to a significant reduction in incidents of distress and helped staff support the person in a safer, calmer and more consistent way. The person experienced less distress, more settled routines and fewer situations where staff needed to use reactive support. This showed the provider used learning to reduce risk, improve the person’s experience of care and embed safer, trauma-informed practice.

The provider always worked with people and other services to establish and maintain safe systems of care. Safety was always managed, monitored and assured during referrals, transitions and changes in people’s support.

The provider had a structured referral and transition process. Leaders gathered information from people, relatives, current providers and professionals to understand people’s needs, risks, communication and support arrangements before care started. This information was used to develop live transition and care plans, which were updated as new information emerged. This helped staff plan support safely and reduce risks when people moved between services or into new living arrangements.

The provider only agreed to support new people when leaders were assured they could meet their needs safely. Where risks were too high, leaders paused or declined referrals rather than starting care without the right support in place. Protecting people from unsafe or poorly planned transitions.

In one example, the provider received additional incident information from hospital shortly before starting to support a new person. Leaders reviewed the risks and agreed a trial period rather than fully starting their care and support without further information, planning and assurance. This showed leaders prioritised safe transitions over accepting support for new people too quickly. People benefited because new risks were reviewed before support started, which reduced the risk of avoidable harm and unsafe support arrangements.

In another example, the provider requested additional commissioned hours to support a person’s safe discharge and transition into the community. This showed the provider advocated for the level of support needed to make transitions safe for people. It reduced the risk of crisis, placement breakdown or staff being unable to meet the person’s needs in the community.

Professionals gave very positive feedback about transitions. One professional described the provider’s transition work as “fantastic” and told us the service took time to understand people with high support needs, arranged core staff teams and engaged in training before their care and support started.

The provider promoted continuity when people moved between services or areas. Leaders arranged for familiar staff to support a person who moved to another city, so the person continued to receive care from staff who knew their communication, risks and routines. This reduced the stress and risks associated with moving to a new area and promoted continuity, reassurance and safer support during the transition.

The provider worked with people and healthcare partners to understand what being safe meant to them and how best to achieve this. 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 understood signs that may indicate abuse, neglect or harm. This included unexplained marks, bruising, weight loss, anxiety, withdrawal, fearfulness, changes in presentation or body language, and other signs of distress. Staff understood that people who did not use words could still communicate pain, fear or discomfort through facial expressions, posture, gestures, Makaton, behaviour or changes from their usual presentation.

Leaders had clear safeguarding systems. Staff knew how to report concerns to managers, on-call staff, local authority safeguarding teams and CQC. Safeguarding records showed concerns were recorded, reference numbers saved and actions tracked. The provider’s safeguarding policy and internal form also directed staff to record and escalate concerns for management oversight.

The provider understood safeguarding risks linked to mental capacity, restrictions and deprivation of liberty. Records showed MCA (Mental Capacity Act), assessments, best-interest decisions, restriction reviews and Court of Protection authorisations were in place where required. This helped protect people from unlawful restriction and supported staff to use the least restrictive approach.

Staff knew where to find information about people’s capacity, best-interest decisions and authorised restrictions. Staff received Mental Capacity Act and restraint training, which helped them understand least restrictive practice and respond safely when people became distressed. Physical intervention was rarely used. When restrictions were needed, staff recorded incidents and managers reviewed whether support remained necessary and proportionate.

Relatives and professionals said the service was open and responsive when safeguarding or safety concerns arose. Professionals said safeguarding referrals were appropriate, timely and investigated. One relative told us “a previous concern about staff conduct was acted on and the staff member was removed from my relative’s care package.”

The provider worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People were fully supported to be involved in assessments and reviews about safety and risks, and staff supported them to take positive risks. The provider involved people, relatives and partners in decisions about risk and focused on promoting people’s rights, independence and quality of life.

The provider did not use risk as a reason to unnecessarily restrict people. Staff used gradual planning, risk assessments, professional advice and family involvement to help people achieve goals safely. This was important because many people had a learning disability, were autistic or had complex communication needs, and some needed careful planning and support around their distress, sensory demands, road safety, risk of choking, and community access.

One person wanted to become more involved in shopping for food and household items. Busy supermarkets had previously presented risks linked to their sensory needs, road safety, financial management and communication. Staff worked with the person’s family, occupational therapy and the Integrated Care Board to plan this safely. Risk assessments considered the person’s transport, emotional wellbeing, communication, personal care needs and staff support.

Staff used the person’s preferred communication methods to seek consent, including gestures, facial expressions, body language and recognised ways they used communication to express themself. Staff introduced shopping gradually and supported the person to access supermarkets, choose items, push a trolley, navigate aisles, take part in meal planning and complete purchases. Following this approach, the person became increasingly engaged, excited and proud of their achievements. There were no significant incidents during these shopping activities.

This had a positive impact because the person gained more choice and control over ordinary daily life. Staff reduced barriers linked to their sensory needs and communication, while supporting the person to take part in shopping, meal planning and purchases safely. The person’s confidence and engagement increased, and they achieved this without significant incidents.

Staff gave further examples of people becoming more independent because risks were assessed and managed positively. One person progressed from being supported with meals to being able to eat independently and communicating when they wanted a drink. Another person increased their confidence in social settings and later watched a football match in a pub. Staff supported people to walk more independently, attend church, access Senad Community spaces and develop daily living skills. This had a positive impact because people gained confidence, independence and greater control over their daily lives.

The provider worked in the least restrictive way. Leaders and staff said physical restraint was rarely used. Staff received training and focused on prevention, distraction, redirection and understanding people’s early signs of distress. One relative told us, “The places the support workers are taking him I would never dream of doing it. I just wouldn’t know where to start. I am so grateful.”

The provider detected and controlled potential risks in people’s care environments and advocated for action. People lived in homes that were assessed, monitored and adapted to keep them safe, while promoting independence, privacy and wellbeing.

The provider supported people to maintain their tenancies and ensured any repairs needed were raised with the landlords of accommodation people lived in. However, the provider had an important role in identifying environmental risks, escalating concerns, advocating for people and working with landlords, housing providers and professionals to help people live in safe and suitable homes. Leaders and staff completed regular checks of people’s homes and equipment to monitor safety. Staff knew how to report environmental concerns and said managers acted when issues were raised. Leaders checked fire safety equipment and used file audits to make sure personal emergency evacuation plans reflected people’s mobility, communication, behaviour and support needs.

Peoples care plans showed they were involved in keeping equipment safe. One person’s plan explained how they worked with their key worker to arrange annual wheelchair servicing and attended the appointment together. A service sticker and calendar reminder helped the person and staff know when the next check was due. This reduced the risk of missed equipment checks and supported the person’s safety, involvement and independence in keeping their environment safe.

The provider understood that safe environments were not only about physical safety. This was important because the service supported autistic people, people who had a learning disability, did not communicate verbally or experienced distress when environments did not meet their needs. Leaders considered how people’s homes affected their emotional regulation, privacy, sensory needs and safety. This helped staff reduce triggers, support people calmly and promote least restrictive care.

The provider used environmental checks and partnership working with people’s landlords to improve outcomes for people. One person’s bathroom and wet room were no longer fit for purpose and created health and safety risks. The provider worked with the landlord, managing agents, health professionals, and contractors to escalate concerns and secure refurbishment. When the person could not safely remain at home during the work, staff coordinated a temporary move, shared key information with the receiving service and maintained contact with the person and their family. This meant the person’s tenancy was protected, risks were reduced and they returned to a safer, improved home.

The provider also recognised when a person’s home no longer met their emotional and environmental needs. Staff worked with professionals, housing providers and the person’s representative to support a move from a flat to a bungalow. The new home gave the person more space, privacy and access to a garden. This had a positive impact because the new home better met the person’s emotional and environmental needs. The additional space, privacy and access to a garden reduced distress, promoted emotional wellbeing and enabled the person to live more comfortably and independently.

Relatives told us people’s homes were clean, tidy and safe when they visited, including during unannounced visits.

Leaders recognised that delays with housing and maintenance could have a direct impact on the safety of people's living environment. Although these issues were not always within the provider’s direct control, leaders did not accept delays as unavoidable. Leaders developed a group of approved contractors who understood the needs of people using the service and could respond more quickly to repairs, adaptations and environmental concerns. This meant people were less likely to experience prolonged disruption or live in environments that did not meet their needs. It also showed the provider took proactive steps to overcome barriers in the wider housing system and help people remain in safe, suitable and personalised homes.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

Leaders matched staff to people carefully, considering staff skills, training, personality, gender where requested, practical arrangements and feedback from people and relatives. Leaders prioritised consistent care arrangements, so people received support from staff who understood their communication, routines and risks. This was particularly important for autistic people, people who had a learning disability or people who did not communicate verbally and needed support to manage distress safely.

New staff shadowed experienced staff before supporting people. One leader told us, “We move staff from care packages if they have not completed the required training or if they are not suited to the person’s needs.” One staff member raised concerns about managing their sleep around night shift hours. In response, the provider moved the staff member to support another person whose care requirements were during daytime hours.

The provider did not routinely use agency staff. Familiar staff, including regular, bank staff and senior staff, covered gaps to maintain continuity. One staff member told us, “Staff from all levels will contribute to ensure continuity and safe care from staff members that know our people the best.”

The provider had strengthened night-time oversight. A night team leader worked from the office overnight and provided immediate advice and escalation support. Waking night staff logged into the provider’s online system every 30 minutes, which gave leaders assurance staff remained awake and engaged. Lone worker safety devices were introduced after incidents involving staff assaults. This improved safety overnight because staff had immediate escalation support, leaders had better assurance that waking night staff remained alert, and lone worker devices helped staff access help quickly if they were at risk.

Staff gave positive feedback about management support, training and teamwork.

Leaders had systems in place to reduce risks through shadowing, staff matching, electronic records, supervision and management oversight.

Recruitment records showed the provider completed pre-employment checks before staff worked with people, including checks of identity, employment history, references, Disclosure and Barring Service information and right to work where required.

The provider assessed and managed the risk of infection. People were protected from infection risks because staff followed infection prevention and control procedures, had access to personal protective equipment and supported people to live in clean and hygienic homes.

Leaders had infection prevention and control policies in place and staff completed relevant training. Staff understood their responsibilities to prevent and manage infection risks when supporting people with personal care, meals, household tasks and community activities. Staff told us they had access to the equipment they needed and knew how to escalate concerns if supplies were low or if a person became unwell.

The provider checked infection prevention and control practice through regular oversight. One staff member told us there had previously been an issue with personal protective equipment stock. They said the provider learned from this and introduced weekly stock checks to make sure staff had the equipment they needed. A deputy manager also told us personal protective equipment was checked daily as part of routine oversight. This helped reduce the risk of staff being unable to follow safe infection prevention procedures.

Staff supported people to maintain clean and safe homes. Relatives told us people’s homes were clean and well maintained when they visited, including during unannounced visits. Staff also supported people with food hygiene, cleaning routines and personal care in ways that respected their dignity and independence.

The provider considered infection risks as part of people’s individual support. Care plans included relevant information about people’s health needs, personal care, food preparation and equipment. Staff monitored people for changes in presentation and escalated concerns to managers or health professionals when needed.

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.

Staff received medicines training and competency checks before supporting people with medicines. Staff checked the time, dose and instructions, gained consent, recorded administration and escalated concerns. If a person refused medicines, staff tried again later where appropriate, asked a familiar staff member to support, recorded the refusal and escalated concerns when needed.

The provider used an electronic medicines system to monitor administration and audit records. Leaders had identified medicine errors as a key safeguarding concern and strengthened oversight through stock checks, live eMAR (electronic medicine administration record) checks and additional staff observations after errors. This helped staff identify errors and discrepancies in real time, including issues linked to GP or pharmacy information.

PRN medicines (when required medicines) were monitored through the electronic system. Protocols told staff when PRN medicines should be considered, the maximum dose and what steps to take first. Staff used reassurance, redirection, fluids, cooling measures and quiet spaces before considering PRN medicines. This promoted preventative and least restrictive support.

Staff recognised when medicines may not be suitable for a person. In one example, staff identified changes in a person’s presentation and behaviours after a new medicine was introduced. They sought urgent medical advice, recorded observations and shared information with professionals. The medicine was paused pending review, which protected the person from potential harm.

The provider considered STOMP principles (Stopping the Over Medication of people with a learning disability, autism or both with psychotropic medicines). Staff understood medicines should not be used to inappropriately control people’s behaviour. This protected people’s rights and reduced the risk of over-medication.