Rose Meadow

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

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 good. At this assessment the rating has remained 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 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.

The provider used a digital system to log accidents and incidents, and we saw that the registered manager reviewed these to identify any themes and trends. Any areas of concern, or good practice, were identified and shared with the wider staff team.

This practice of continued learning and ongoing improvement was embedded and supported ongoing good practice which improved the safety of people living at the services.

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 carried out assessments for people referred to the service. They worked in conjunction with the person, relatives, the current care provider and other professionals. This ensured the person’s needs could be met by the service, and compatibility with existing people was carefully considered to ensure people were suitable to live in the same environment and minimise the risk of any conflict.

People had a detailed hospital passport in place, this supported with a smooth transition if a person needed to attend hospital and provided medical professionals with details about their clinical needs, communication style and personal preferences. People were engaged in the process of planning to move between different services together with relatives and professionals.

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.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority. Any conditions related to DoLS authorisations were being met. The documentation supported that each DoLS application was decision specific for that person. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to make decisions; any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

Staff had received appropriate training, had access to policy guidance on safeguarding and demonstrated good knowledge of safeguarding. Staff had a good understanding of things which presented the risk of harm to specific individuals and how to manage this, and people were supported to ensure their safety. We asked staff about how they kept people safe from harm and how they knew what to do. One staff member gave an example of checks carried out to support people’s safety. They said, “Firstly, we are trained in what types of abuse exist and what signs, symptoms and behaviours a victim of these abuses may exhibit. Checks for a lot of these abuses are built in to our every-day procedures, such as daily financial checks, and regular skin integrity checks where any new injuries or conditions are recorded and escalated as appropriate.”

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 supported to do the things that mattered to them including attending day services and various outings which were risk assessed. For people with limited verbal communication care plans emphasised people’s preferred means of communication to support their understanding and ability to make informed choices by providing information in a way that they understood.

We saw examples of positive outcomes for people including support one person received with weight loss to address a risk to their health.

Risks were assessed and mitigation was in place which kept people safe whilst promoting them doing things they wished to do.

The provider had not consistently detected and controlled potential risks in the care environment. We found that mats on the floor were not appropriately secured presenting a risk of slips and trips. We also found that radiators in some areas were hot to the touch and not appropriately covered meaning people were at risk of scalding. The management team responded quickly and removed or secured the mats. The registered manager reported the concerns regarding radiators and were waiting for the maintenance team to address this. The risk was mitigated short term through staff support of people accessing areas where we found concerns with radiators.

We saw that staff carried out health and safety checks and engaged people where possible in maintaining their home environment as well as where issues had been reported to the maintenance team to support with maintaining a safe living environment for people.

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.

We reviewed documentation that evidenced staff received regular supervision to support their development which staff confirmed. Staff received an induction, they shadowed experienced staff and training was completed, including person specific training, to ensure staff had the right skills to safely support people. Staff confirmed they felt supported and were encouraged to undertake training and develop their skills and knowledge. One staff member told us, “I feel well supported by leaders and able to ask for help and escalate issues. The whole staff team are approachable and helpful.” We did not observe any concerns regarding staffing levels and people and relatives did not highlight any issues.

The provider followed a safe recruitment process and had an appropriate supporting policy.

These processes ensured people were supported safely by appropriately trained staff who were matched to the needs of people to enable them to work towards and achieve their aspirations and potential.

The provider did not consistently assess and managed the risk of infection.

We identified that pull chords did not have an appropriate covering to ensure they could be kept hygienically clean which we discussed with the registered manager at the time who confirmed this would be addressed. We found a device used for killing flies was not appropriately placed in the kitchen meaning food could become contaminated. The device was not currently in use, and the registered manager advised it would be moved to an appropriate position in the kitchen.

The home, furnishings and equipment were found to be clean with no malodour, staff had access to appropriate personal protective equipment, and the provider had a current infection prevention and control policy to guide staff. Staff ensured people were supported with their personal hygiene and clothes were clean.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

We found protocols for as required medicines, for example paracetamol, were in place but staff did not consistently record the outcomes of taking this medicine. The management team addressed this promptly.

Medicines and creams were all in date and appropriately labelled on opening. Items were stored in person specific trays and plastic baskets which were clean and ordered. There were no gaps in medication administration records, including topical medicines which had supporting body map documentation in place.

Staff had all received appropriate training and competency assessments for administering medicines.