Bradford Regional Office

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Whilst we found no harm to people, improvements were required, to ensure the management team had effective oversight of all accidents and incidents. For example, we found several incidents which were not reviewed by the registered manager, and we found not all incidents of distress or falls were appropriately reviewed, meaning there was a lack of overall monitoring for themes and trends and a lack of evidence about how lessons were learnt. We also found a lack of detailed records in relation to how people were presenting during incidents of distress and how staff had supported them to calm. However, staff had recorded accidents and where required appropriate interventions were sought from external professionals. For example, staff had sought emergency medical treatment for a person, and another person was awaiting input from an occupational therapist, following some falls. There was also post falls analysis and observation in place. The service had identified that they did not have effective oversight of all accidents and they were in the process of reviewing their systems to make them more robust and provided evidence of how they were doing this. We did not see anyone had been harmed or put at risk.

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 had pre assessments in place prior to receiving support from the service. Care records were digitilised and could easily be shared between services where appropriate.

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.

At the time of our assessment one of the homes was placed in organisational safeguarding by the local authority, due to an increase in safeguarding concerns. The provider was working closely with the local authority to ensure people were safeguarded and risks posed to people were mitigated. Professionals told us improvements were being made and they were working closely with the service to embed improvements. There were clear systems and information provided to staff about safeguarding vulnerable adults and keeping people safe. Staff understood their roles to whistle-blow on poor practice and told us they felt comfortable to report concerns, and action would be taken. A staff member said, “I know the whistleblowing policy. It means I can report poor practice safely. I’d contact the manager if needed, they are approachable.”

People were only restricted or deprived of their liberty when it was in their best interests and had been properly authorised under the Mental Capacity Act (MCA). In supported living, this authorisation must come from the Court of Protection. The service followed the principles of the MCA. People’s capacity was assessed, and Court of Protection orders were in place where required.

Improvements were required about how the service monitored incidents of distress. Whilst the provider had a specific team in place to monitor this, not all incidents were reviewed as part of this analysis. However, this had no impact on people, we found several people who had a reduction in behavioural incidents, and this in turn had meant a reduction to some of their medicines and staff support. This ensured people were provided with the least restrictive options. People had risk assessments in place and associated care plans. People were supported to take positive risks. For example, people were assessed to ensure they were safe accessing the community independently, others were supported to self-administer medicines and manage their own finances.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had systems in place to monitor the safety and suitability of the environment. Regular health and safety checks were in place, to ensure risks posed to people from the environment were mitigated. This included fire safety checks and fire drills.

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. The management team informed us they only used agency staff in emergency situations and people were mostly supported by a core staff team. Most people and relatives told us they were supported by enough staff, who cared for them well. A relative said, “The best thing is the way the staff understand [name]. It is amazing. If new staff come, they shadow the experienced staff for ages, so that they really get to know [name]. The staff who know him will always come over to help if [name] is distressed.”

Staff were recruited safely, and all pre-employment checks were in place prior to working. Staff received an initial induction, and ongoing support. Staff were trained in a range of subjects, including specialist training, including rescue medicines, supporting people with learning disabilities and epilepsy. Staff had received specialist training in relation to positive behavioural support and training was tailored for each individual, to ensure staff had the skills to safely support people during incidents of distress.

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. Policies and procedures were in place about how staff kept people from safe from the risk of infection. People told us staff kept their homes clean. A relative said, “The property is extremely clean. The carers do all the cleaning. [Name] was the first person to move into the house when it was first built, it is lovely.” Staff told us they were provided with personal protective equipment (PPE). A staff member said “I have received infection prevention and control training. I follow standard precautions such as regular handwashing, wearing PPE, proper waste disposal, cleaning and disinfecting equipment, and following isolation procedures when needed."

People’s medicines were mostly managed safely. However, we found a MAR chart which some missing records, such as allergy information. This was a recording concern. People had received their medicines as prescribed, and people told us staff administered their medicines on time. Where people received 'as required medicines' there were detailed protocols in place, about how and when these should be administered. Staff were trained prior to administering medicines to people and had their competencies assessed. The service worked within the principles of STOMP. The STOMP initiative focuses on Stopping Over Medication of People with a learning disability and autistic people.. People had regular medication reviews undertaken.