2 Millbrook Way

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.

The provider was previously in breach of the legal regulations in relation to safe care and treatment and safeguarding. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

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 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.

Processes were in place to ensure safety incidents were appropriately investigated and reported, and outcomes shared with the team.

Management had implemented systems to ensure risks were well managed and staff confirmed they were involved in debriefs to review and reflect on incidents. Family members were made aware of events and worked with management to seek solutions.

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 management team worked with community based professionals to access health and social care support in their local community.

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.

Observations showed people were happy and felt safe in the company of staff. Most relatives and staff were confident if they raised concerns with management appropriate action would be taken. One relative told us, “We do trust that [family member] is safe as can be. They [staff] watch him all the time.”

The service had clear safeguarding systems and processes to protect people from abuse and neglect. Staff had access to safeguarding training and the service’s policies advised them on how to respond if they witnessed poor practise. When appropriate, management notified the local authority, specialist health professionals and ourselves when concerns had been raised.

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

Staff felt care plans and risk assessments guided them on how to manage risk. They said they felt competent and supported to be able to prevent or respond to behaviour that communicated a need, emotions or distress.

The management team worked with specialists to manage risks related to people’s physical and mental health.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

One relative expressed concerns that the environment was unsafe for their family member. This was discussed with the provider who was aware of the concerns and was communicating with the family.

Staff had good knowledge of fire safety procedures, and every person had a personal emergency evacuation plan (PEEP). The purpose of a PEEP is to ensure that all people can evacuate the building safely and promptly in the event of an emergency, regardless of their level of mobility or other health conditions.

The service was well maintained, free from trip hazards with exit doors locked where necessary.

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 provider ensured people received the level of staff support that had been identified by the local authority. One person did not always have suitable staff support due to a lack of funding. The manager was discussing this with the local authority.

Staff said they had an induction when they started working for the service. They felt they had enough training to do their job well, received regular supervisions and felt supported by the manager. One staff member told us, “If you need extra support, it is available. Management are very supportive.” A second staff member said, “I loved the training, and the induction was really good, really informative.”

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.

People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. People received support to maintain their own personal hygiene in line with their needs and preferences.

PPE was available to staff who knew when to wear it and how to dispose of it.

Observations showed the premises and equipment was clean. A sign in the kitchen promoted safe infection prevention behaviours. It stated, ‘If it smells throw it away. If it’s dirty wash it. If you get it out, put it away. If it’s on, turn it off.’

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Best practise was not consistently followed on the storage and recording of medicines. Medicine totals checked did not consistently match on site records. One person with diabetes did not have their blood glucose levels consistently recorded. When blood glucose levels went outside of safe guidelines, staff took responsive action but never took follow up actions to see if their interventions had been successful.

Fridge temperature checks were not consistently completed. Medicines being stored outside their recommended ranges may reduce their therapeutic effectiveness. The manager took immediate action to address these concerns.

Staff were trained and regularly assessed as competent to manage medicines safely. They had good knowledge of people’s medicines, and understood processes around it’s ordering, recording and storage.

The manager worked with health professionals to review people’s medicines. Guidance was available for staff to review on the over medication of people with a learning disability and autistic people, in line with STOMP principles. STOMP is a national NHS England work programme to stop the inappropriate prescribing medications.