Wentworth Close

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 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff reported safety events. Lessons were learnt to continually identify and embed good practice. The service had a positive behavioural support (PBS) lead who monitored all accidents and incidents and any learning as a result was shared with staff through staff meetings and staff handovers. A health professional told us “[Staff member] has extreme diligence, attention to detail and professionalism and [their] standards of care are outstanding.” People’s relatives told us they felt comfortable raising concerns. A relative told us, “Staff are available if any concerns come up.”

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 a care passport to take with them should they be admitted to hospital. This set out important information for hospital staff to understand risks associated with meeting their individual needs. Staff supported people to attend healthcare and hospital appointments to share information and record advice received. When a new person moved to the service a staff member from their previous placement transferred to the service. This made the move easier for the person and the staff team had advice and support on how best to care for the person.

The service 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.

During our assessment everyone received one to one support, and we saw positive interactions between people and staff. People’s relatives told us their loved ones were safe. A relative told us, “When [Name] needs changed, [the provider] brought in extra staff straight away, they didn’t wait until the funding was agreed. This was excellent and we appreciated that.”

Staff received training in safeguarding and told us they would report any concerns about people to their manager. The manager understood their role in raising and managing safeguarding concerns and making referrals to the local safeguarding team. When people were identified as potentially being deprived of their liberty, applications were made to the authorising body as required.

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.

Individual support plans included a range of risk assessments that considered the person's environment, care, and treatment, medicines, and activities. Where there were particular risks, for example in relation to managing people’s emotions, epilepsy or choking, support plans were detailed and informed staff of the actions they needed to take to keep people safe and reduce the risk of harm. When individual needs were identified, people were referred for specialist support to ensure risks were managed effectively and safely. Staff were able to talk about the actions they took to minimise the risks of situations escalating and how they kept people safe. Staff kept records of any actions that indicated people might be distressed.

Records did not always demonstrate that a debrief had been held with the staff concerned following incidents, but the PBS lead analysed all records weekly to ensure that any lessons learnt could be carried forward. Following one incident the carer requested clearer advice on how to support the person as they had not experienced that type of incident before. The manager confirmed this would be arranged.

Environmental audits were carried out at regular intervals and areas noted for attention were dealt with appropriately. Regular health and safety monitoring ensured that all servicing of gas, electric, portable appliances and water safety were kept up to date. Staff had received fire safety training and information described the support people needed to evacuate the building in an emergency. We saw that some people when asked where they should go if the alarms sounded, were able to point to the designated area. The provider had processes to ensure the premises and equipment were maintained in good order.

The provider did not always make sure there were enough experienced staff available at weekends. People were supported to go out daily through the week if that was their wish and there was evidence that people had regular opportunities to do so. Some staff told us that it was not always possible to take people out at the weekends. This was due to a shortage of drivers, agency use, (some people could only be supported by permanent staff) and some people needed two to one support. However, a staff member told us, “We make the best of what we can do indoors. We do baking and have garden games.” They confirmed that people still received their one-to-one support.

A person’s relatives told us that all the permanent staff were, “Excellent.” They said that sometimes some agency staff were seen to be watching TV and were less inclined to interact well with people as they did not know them as well as permanent staff.

The PBS lead felt stretched in their role as only one day a week was allocated to the task. This made it difficult to respond to matters in a timely way. For example, reviewing of incident reports. Whilst the manager reviewed incidents as they occurred, the implementation of any responses based on the overall analysis of incidents was delayed until the PBS lead reviewed the report. The manager also felt that not enough time was allocated to this role and had raised this subject with the area manager. The area manager confirmed they were looking to review this role.

The provider followed safe recruitment procedures to ensure people were supported by staff who were fit and safe to support them. Recruitment records included satisfactory references, employment history, and criminal records checks. Staff received a detailed induction to the service. The manager told us there were two staff vacancies and that these hours were covered by regular bank and agency staff. Staff told us there was an on-call service that was displayed in the office for out of hours advice and support. Staff told us they attended regular supervision meetings to support them to do their jobs well.

The provider assessed and managed the risk of infection. Cleaning schedules were completed daily, and audits carried out to ensure all cleaning had been completed as planned. People’s relatives and visiting professionals told us they had no concerns about the cleanliness of the environment and staff practice.

Care staff had received training in infection prevention and control and had access to personal protective equipment (PPE). Staff knew when and how to use PPE correctly and how to prevent the risk of infection. Staff had completed food hygiene training to ensure that they understood how to handle, prepare, and store food properly to prevent illnesses.

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.

We found excess stock in one person’s medicine cabinet. The stock was from 2024, and it was not clear why this had not been returned to the pharmacy. Following our visit the manager confirmed the excess stock had been returned.

Staff told us that one person was given ‘as required’ (PRN) medication in certain situations. A staff member stated that they should not wait for the situation to escalate they should give it straight away. However, the protocol did not clearly state this. We asked the staff member to review this advice with the professional concerned and ensure that the protocol was updated. All staff were clear about when to give this medicine, and it was noted that only permanent staff supported this person in relation to this need so the impact of not giving it promptly was low. Following our visit, it was confirmed in writing that the protocol had been updated.

An assessment of how people indicated when they were in pain and if they were independently able to ask for pain relief had been carried out. Staff had accurately completed people’s medicines administration records, which confirmed that people using the service had received the correct doses of medicines at the right times.

Staff received medicine related training which supported them to safely carry out their role and they were assessed in terms of competency before they started to support people with their medicines. Each person had recently had an annual health review. A health professional told us that arrangements were being made to ensure that the service had a weekly call to check if people had any medical support needs.