3D Healthcare Solutions 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 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.

Effective procedures were in place for analysing incidents and accidents. The provider’s complaints folder indicated they had received no complaints over the past year. The registered manager explained their complaints process and how they would achieve a satisfactory resolution when handling a complaint.

Communication with staff was robust, with regular team meetings taking place. All appropriate information about people’s care, and any changes in risk or needs, was recorded on each person’s electronic file, so staff could readily access this. All staff had appropriate induction training to identify, and report concerns to their manager, with follow up meetings taking place.

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 experienced well-coordinated transitions, with staff obtaining relevant information from family members and previous services to ensure continuity. A relative described the process as “well executed”, explaining it made the family feel “involved and informed”.

Staff understood referral pathways and used them appropriately. This included referrals to speech and language therapists (SALT), occupational therapists and district nurses when people’s needs changed. The provider was able to evidence timely professional involvement for people’s ongoing medical health care needs.

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.

Staff understood their safeguarding responsibilities and followed the provider’s processes to raise concerns which protected people from the risk of abuse. Staff received safeguarding training from the provider, and confirmed they felt confident to escalate issues both to their manager and to the local authority. Staff told us people were mostly non-verbal and they looked for changes in their facial expressions and body movements to monitor for changes in mood. They understood the need to report and record any unexplained injuries. A staff member told us, “I would use a body map chart if I found bruising and let the manager know. We complete body maps every month too, when we complete the resident health checks.” Another staff member told us, “We look for changes in mood and body language to see if something might be wrong.”

A relative told us “[Person] is very happy now and you can see [person] is growing in their own home now. The staff treat [person] like an equal and really take care of them.”

No one using the service was being deprived of their liberty at the time of the assessment, but the manager understood the process for authorising this and the appropriate polices were in place. Processes around authorising a deprivation of liberty are important human rights safeguards; they aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests.

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.

Care plans and risk assessments contained detailed guidance for staff to follow, including how to communicate effectively with people and support them safely whilst eating, providing personal care and taking medication. Staff we spoke with understood risks to people and how to support them to remain safe. Staff understood the needs of people with complex health conditions. Staff had a good understanding of the people’s care requirements and how they like them to be completed.

Care plans and risk assessments were reviewed in line with the provider’s policy, as were individual goals set out for each person using the service. Annual reviews included the person, and family member where appropriate, and all changes to care plans were agreed with people and family members where appropriate.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care.

There was a heavily worn section of carpet in the main living room that posed a trip hazard. Additionally, a grab rail, over the bath in a communal bathroom, had been pulled out on one end, removing a bath tile with it, and had exposed screws. Following our site visit, the manager confirmed steps had been taken to rectify these faults; however, the provider’s auditing process to check the home for safety concerns was not robust.

The provider had appropriate safety certificates in place and a detailed history of servicing information.

The home was modern and the landlord had been responsive in making repairs when required.

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.

Rotas showed consistent staffing levels, and staff described good teamwork and support from the manager.

People were supported by staff who had been recruited using safe recruitment processes. This included checking new staff members’ work histories and ensuring staff had a Disclosure and Barring Service check (DBS) in place before they supported people.

Staff had completed appropriate training to care for the people using the service, including learning disabilities and autism training. The provider evidenced they regularly completed competency checks on all staff after training has been completed, and staff have 3 competency checks completed before they can work unsupervised.

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.

The property was clean and tidy. Cleaning schedules were in place, and daily temperature checks had been completed for the refrigerator and freezer to ensure these were operating within a safe temperature range.

All staff were wearing appropriate personal protective equipment (PPE) and guidance on handwashing was located in the kitchen. Audits showed consistent cleanliness checks, and no gaps in cleaning records. Staff meeting minutes demonstrated expectations around cleanliness were regularly discussed, and staff confirmed the cleaning schedules were completed daily.

Feedback we received in relation to the cleanliness of the service was positive. One relative told us they could smell cleaning products had been used when they attended the home and that it was always clean and tidy.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always ensure discontinued medicines were immediately removed to prevent administration.

We saw one person’s ‘as required’ (PRN) medication, stopped 12 months earlier, had not been removed from the premises and was still on their medication administration record (MAR). Although this medicine had not been administered since discontinued, the failure to remove this medicine from the premises and to update the person’s MAR increased the risk of medication errors. Following our assessment, the registered manager assured us this medicine had now been removed and the relevant MAR updated.

Staff received appropriate training and had their competency evaluated before being allowed to administer medicines to people. Records demonstrated people’s MARs had been completed accurately and in line with best practice guidance, aside from the error involving 1 person’s PRN medicine referred to above. Staff ensured people’s current prescribed medicines were stored safely in line with best practice guidance.

There was clear guidance in place, in the form of PRN protocols, to ensure staff knew when to offer people PRN medication, and there was evidence of staff administering this medicine when necessary.