Capricorn Cottage

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 75 (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 registered manager had encouraged learning from events at the service. They analysed incidents looking for trends, shared this information with their staff team and put in processes to reduce the risk of recurrence. Staff meetings showed evidence of how staff were encouraged to discuss events and whether the responses to these events had a positive impact on the people they supported.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

People and their relatives told us they were safe living at the service. People enjoyed living there and felt able to speak with staff if they had any problems. One relative said, “I would say [Name] is safe. They (staff) have good safety measures in place in line with DoLS (Deprivation of Liberty safeguards) and stuff. Because of [Name’s] disability, they always have one-to-one (staffing) and two-to-one (staffing) in the community. So, they always have someone looking out for them, even in the residence.”

Staff all had a good understanding of their role in safeguarding the people they supported. All the staff we spoke with knew the different types of abuse people could be exposed to and what they needed to do to keep people safe.

The registered manager worked with her managers and the local authority safeguarding teams to ensure any safeguarding issues raised to her were dealt with effectively. The registered manager had also installed a post box outside her office so staff had the option to raise any issues to her anonymously to ensure she did not miss any possible concerns.

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. There was good evidence to show how people had been supported with positive risk taking to encourage their independence. There was information to show how people should be supported when going out into the local community and how staff should offer encouragement to ensure people lived as full a life as possible. Some people showed anxieties when going out and their care plans had guidance for staff to effectively support them by offering regular activities they enjoyed. People were supported in line with the information in their risk assessments and care plans. Where people were recorded as needing mobility aids to help them move around the service, these were in place. When people were at risk of seizures there was information in their care plans to ensure staff supported them safely. One person required their supporting member of staff to have rescue medicines with them at all times and we saw this was in place when we visited.

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

People lived in a safe environment. The registered manager worked with the provider’s estates team to ensure there was good oversight of areas such as fire safety or monitoring legionella testing. There were window restrictors on windows so they could be opened safely.

There was regular servicing of equipment used at the service. This included heating systems, kitchen equipment and moving and handling equipment.

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.

People were supported with safe numbers of staff. There was positive feedback from relatives on how well staff worked to support their family members. One relative said “Yes, definitely. I mean, [Name] is on one-to-one anyway throughout 24/7 and they're (staff) always there for him. When we go through to the other part of (the service) there always seems to be a lot of staff there, which is really reassuring because then if anything happens with [Name] and they need someone else, there's always someone they (staff) can call on, which is, as I say, reassuring.”

Staff were generally positive about the staffing levels and felt they were safe. One member of staff said, “They (managers) do try to cover shifts, if this happens they put requests for extra shifts on an employee chat group thing. They (shifts) are mostly covered.” One or two staff identified there were busy periods where an extra member of staff may be useful such as mealtimes. However, we observed the lunchtime experience during our visit and although it was a busy period, people who needed support with eating received this in a timely way.

Staff recruitment processes were safe, the files we viewed showed that the provider had used the disclosure and Barring Service (DBS) checks prior to employment. This service will give employers information about any previous criminal convictions a prospective employee may have and helps the provider make safer decisions when employing people. There were a number of overseas workers employed at the service and we saw evidence of their right to work in this country.

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 lived in an environment where staff worked to protect them from the risks of infection by following safe infection prevention and control (IPC) practices. Relatives we spoke with felt the service was clean. One relative said, “Yes, it's always clean, always looks clean, yes, the carpets everywhere do look clean, and I usually have a drink there and I'll go towards the kitchen area and it always looks clean.”

Throughout the service we saw areas such as the kitchen, laundry room, communal areas and people’s rooms were clean. There were cleaning schedules in place and the management team undertook regular audits of the different environments to ensure they were clean.

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.

People were supported with safe numbers of staff. There was positive feedback from relatives on how well staff worked to support their family members. One relative said “Yes, definitely. I mean, [Name] is on one-to-one anyway throughout 24/7 and they're (staff) always there for him. When we go through to the other part of (the service) there always seems to be a lot of staff there, which is really reassuring because then if anything happens with [Name] and they need someone else, there's always someone they (staff) can call on, which is, as I say, reassuring.”

Staff were generally positive about the staffing levels and felt they were safe. One member of staff said, “They (managers) do try to cover shifts, if this happens they put requests for extra shifts on an employee chat group thing. They (shifts) are mostly covered.” One or two staff identified there were busy periods where an extra member of staff may be useful such as mealtimes. However, we observed the lunchtime experience during our visit and although it was a busy period, people who needed support with eating received this in a timely way.

Staff recruitment processes were safe, the files we viewed showed that the provider had used the disclosure and Barring Service (DBS) checks prior to employment. This service will give employers information about any previous criminal convictions a prospective employee may have and helps the provider make safer decisions when employing people. There were a number of overseas workers employed at the service and we saw evidence of their right to work in this country.