Leicestershire Community Support Scheme

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 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 promoted a positive culture of safety based on openness and honesty. Staff listened to concerns, reported safety events and ensured these were investigated. Lessons were learned and used to improve practice. People knew who to raise concerns with and felt confident to do so. Staff described how they recorded incidents, which were reviewed by management to identify improvements. We reviewed several safety incidents on the electronic system and saw action plans had been put in place. These were monitored with oversight from the area manager. Medication errors were investigated and appropriate actions taken to reduce the risk of recurrence with a local action plan. Relevant parties were informed of outcomes. Minutes showed how learning was shared with staff, for example following a complaint about a person’s being unkempt. Staff confirmed learning from incidents was consistently shared with them and involved family during feedback.

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. A person described how staff had supported them to move from their previous home to their new home. They told us, “I like to garden and grow things and staff make sure I have an area outside my flat which I use to garden.” Relatives described how they had been consulted and included in assessments before people began to use the service. This helped to ensure people were supported in the right environment and had a staff team that was compatible with their needs and interests.

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. For example, a medication error was identified when medication was administered outside the scheduled time. No adverse effects were reported, and the staff member self-reported the incident. The provider responded by delivering retraining on medication administration protocols and increasing supervision. This was treated as an isolated incident and not indicative of a wider pattern. Staff demonstrated a clear understanding of safeguarding procedures, including how to report concerns and escalate issues appropriately. A staff member told us, “We are able to raise any concerns or issues quickly and they are listened to and acted on. For example, we had some issues with a person’s family who lacked trust in staff. Our senior worked with them and staff to build trust, and we now have a really positive relationship which benefits the person.” The provider had embedded a culture of learning from incidents, and we viewed minutes from staff meetings where support workers reflected on recent events and discussed improvements. These included incidents where people had become distressed and included an analysis, de-briefing and reflection of what could have been done differently. These sessions promoted accountability, strengthened communication, and reinforced safe practices. Staff were encouraged to share experiences and apply learning to prevent recurrence, contributing to a proactive and transparent safeguarding environment.

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 supported safely by staff who understood and followed guidance in people’s care plans to mitigate risks. Risk assessments were personalised and included detail and guidance in relation to people’s specific conditions such as epilepsy or other specific healthcare conditions to show potential risk factors and how this was being mitigated. People and relatives told us they felt safe with staff and felt their homes were safe and secure. A person told us, “Yes, I definitely feel safe with all the staff. I would tell the manager if I didn’t”. A relative described how staff had consulted them around specific risks associated with their family member. They told us, “They really listened to us regarding the risk of [Name] putting themselves at risk of harm. Staff removed any items that could be used and checked regularly. As a result, this risk is no longer an issue.” Where people experienced distress, care plans included positive behaviour support strategies that followed best practice. The provider did not practice physical restrictions and provided staff with specific training around understanding learning disabilities, autistic people and distressed behaviours. This gave staff the knowledge and skills they needed to support people safely using the least restrictive interventions.

The provider assessed people’s home environment to identify any risks. When risks were identified, the leadership team discussed these with people and their families and developed plans to help mitigate risks. For example, staff had identified some people would be at risk through their response in the event of having to evacuate in an emergency. Staff had worked with the person, family and agencies and identified mobility vehicles would be used to evacuate people to as this would make them feel safe. A relative told us, “[Name’s] home is really tidy, safe and well maintained.” Staff liaised with other professionals when they identified people needed or would benefit from equipment. For example, they had alerted other professionals when a person needed specialist equipment to keep themselves safe in the bathroom. They also liaised with professionals who carried out services on equipment to make sure this equipment was safe to use.

The provider strived to ensure there were enough qualified, skilled and experienced staff, who were supported in their roles through supervision and development. However, there appeared to be inconsistencies in staffing in a small number of services. Comments from people and relatives in affected services included, “No there isn’t enough staff because I get my set hours, and this is delivered in blocks but sometimes they don’t have enough to cover everyone and it’s a problem…. but it’s getting better” and “Staffing is always a bit of an issue because if someone is sick it is difficult to get cover. It’s more of an issue around weekends and bank holidays.” We raised this feedback with the registered manager who was aware of concerns and had begun to implement improvements. Staff told us they had good levels of support and praised the training they received. A staff member told us, “People are complex, and we have to take time to learn to get to know them as individuals and communicate with them. The training is very good for that. I spent the first 3 months on induction, shadowing staff and learning about people and needs which I really appreciated; it wasn’t rushed.” Safe recruitment procedures were followed to ensure staff were safe to work with people. This included requesting and receiving references and checks with the disclosure and barring service (DBS). DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people.

The provider assessed and managed the risk of infection. We received feedback from people and relatives who were satisfied with the infection control measures employed by the service. Daily care records showed regular cleaning being undertaken by staff as agreed in people’s care plans. Staff had access to personal protective equipment (PPE). Staff received training in infection, prevention and control and food hygiene to support good practice in this area.

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. People said they received their medicines when needed. A relative told us, “[Name] has some support with their medication and this is done safely.” People were supported to manage their own medicines where this was possible. A person told us, “I manage my own medicines; staff don’t need to know or help me with these, but they are there if I need them.” Staff received appropriate training and had their competency to administer medication regularly checked by the management team. Care plans and risk assessments were in place to guide staff. This included information for care staff on when they can give ‘as required’ medicines such as paracetamol when people expressed pain, and guidance around the administration of specific medicines including those for diabetes. The provider had systems and processes for the safe management of medicines. Regular medicines audits were undertaken by the registered manager and actions taken in the event of any errors or discrepancies being identified.