243 Church Street

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 provider used an electronic care records system which was linked to each person’s care plan. The provider also recorded any incidents that occurred. Staff and leaders used this system to review historical care records and identify emerging patterns or themes. These insights enabled them to enhance practice and provide more effective support, ultimately helping people to improve their overall wellbeing.

Regular supervisions were held, with staff being asked to reflect on their practice and identify any opportunities for improvement on the way they cared for people. Staff meetings and daily handover meetings were used as opportunities to share best practice and improve outcomes.

Leaders had audit processes in place where care records and incident reports were checked over so any learning opportunities could be identified.

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 provider had a robust referral and induction process which informed the care plans created for new admissions. Multi-Disciplinary Team (MDT) meetings and visits from the GP were held on a regular basis. Leaders were knowledgeable about people’s needs, and which external agencies were involved in each person’s care.

Systems were in place to ensure people’s safety. Care notes were completed consistently by all staff, giving detail of any concerns relating to each person. This allowed the provider to give a detailed and accurate handover to health and social care services who worked in partnership. Handover meetings were held at the beginning of each shift which were well attended by staff, this ensured continuity of care and regular communication.

A relative told us, “The care plan is updated and there is regular contact about any issues and plans.”

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 and leaders were aware of safeguarding processes and when to make a referral. All staff received training on safeguarding.

Leaders maintained comprehensive audits covering incidents such as falls, accidents, and medication errors.

The provider was knowledgeable about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) legislation. This legislation protects the rights and ensures that the least restrictive practice is used when caring for people who lack the mental capacity to make particular decisions. Where appropriate, the provider had applied for DoLS authorisations and had assessed people’s mental capacity in each area of their care, recording detailed best interest decisions in areas of care where the person was found to lack capacity.

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.

People were encouraged to take positive risks to maximise their independence. For example, a person liked to make their own cup of tea, despite there being a risk of scalding due to their mobility and cognition. Staff remained close to the person to support them and encouraged them, intervening only if the person required support. Instructions on how to support the person were written in their care plan and a risk assessment had been completed, this was regularly reviewed. This showed the provider assessed risk and kept people safe but were also proactive in encouraging people to maintain their independence by supporting them to complete their own activities of daily living when they were able to.

Where appropriate, people and their relatives were involved in decision-making about managing risk.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental checks were thoroughly completed on a regular basis, and actions were taken when issues were found.

The building was spacious, with wide corridors, large bedrooms and communal areas.

The provider had a locked front door and staff checked visitor’s identity before admitting them into the building to keep people safe.

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.

Staff retention was high, with all staff being permanent. Staff were observed working safely with people, showing a compassionate and knowledgeable approach to meeting their needs.

Staff were given comprehensive training for their roles, with regular updates and specialist training modules being given to provide a better understanding of people’s specific needs. Staff were encouraged to give feedback on training they had attended to improve quality. They were encouraged to identify opportunities to further their learning and development if they felt that they needed to gain more skills and experience in a particular area.

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.

All staff completed training in infection control and took responsibility for cleaning. There were processes in place to manage infection control. Cleaning rotas were completed daily, with audits being completed on a regular basis to ensure compliance.

The provider had systems in place to reduce the risk of infection. For example, there were 2 separate washing machines on site, with laundry items that were slightly dirty being washed in the kitchen, and any more heavily soiled items being washed in a separate laundry room outside of the main building.

Cleaning chemicals and equipment were stored in a locked cupboard which was only accessible to staff, preventing unauthorised access to harmful substances and items.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Processes were in place for the ordering, storage and administration of medication. Mandatory training was in place for all staff who administered medication, with additional support and training being provided by qualified nursing staff.

Regular MDT meetings were held with each person’s GP, with any changes in their presentation being discussed with the GP. This meant that medication could be changed and optimised on a regular basis to ensure it was meeting each person’s needs.

Staff who administered medicines were knowledgeable and understood the processes in place. This meant medicines were administered to people safely following agreed protocols.

Regular medication audits were carried out by leaders. Analysis was completed as part of the audit which identified if any actions were required to maintain safety and improve quality. This meant any issues could be reflected upon and actions taken r to improve practice.

Where appropriate, people’s medicines were stored and administered to the person in their room. This meant people took their medicines in privacy.