6 Celtic Farm Road Also known as Rainham Library

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

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 the same. 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 had robust systems in place to help ensure that accidents and incidents were recorded, logged appropriately and were analysed by senior staff to identify patterns, root causes, and contributory factors.

Management conducted investigations into the incidents that occurred and developed action plans, which were subsequently reviewed in accordance with the improvements implemented. Lessons were learnt as part of the review and shared with staff. This approach supported the ongoing development of the service and contributed to the lessons learnt process.

All staff received regular supervision which focussed on accidents, prevention strategies, and reflected on lessons learned.

One staff member said, “We receive feedback in supervisions regarding incidents or accidents that have taken place, and the learning from them. We also receive updates by email from management about any changes to people’s care plans and risk assessment.” Another staff member told us, “The manager always feeds back any lessons learnt from incidents that have taken 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.

Systems were in place to capture information as part of the pre-assessment process to determine if the service can support people safely. Pre-assessments were carried out to confirm that the service could adequately meet each person's needs. Information was easily accessible for sharing with appropriate healthcare professionals as required.

Following the completion of initial assessments, the registered manager explained that comprehensive care plans and risk assessments were developed for each person. These documents outlined the specific needs, preferences, and potential risks associated with the person's care. Care plans and risk assessments were shared with all relevant staff. This process ensured that staff were fully informed about how to provide safe and personalised care.

One relative told us, “The management carried out an assessment before support began, which helped ensure that the right staff would be supporting my relative. We were also given a copy of the assessment”.

Staff confirmed that they had access to systems, which would hold vital information about people they support. One staff told us, “We are given people needs assessments and risk assessment prior to us going into people’s homes. This helps us to understand how we will be supporting individuals and ensuring they would receive the appropriate care and support”.

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.

Comprehensive systems and processes were established within the organisation to ensure that people were safeguarded effectively from the risk of abuse. These systems included robust policies and procedures, which outlined clear steps for identifying, reporting, and responding to any concerns relating to abuse or neglect. Regular audits and reviews of safeguarding practices were conducted to maintain high standards and to adapt procedures in line with current legislation and best practice guidance.

The registered manager demonstrated a clear understanding of their roles and responsibilities in protecting people. They were confident that staff had the skills to identify potential safeguarding issues and knew precisely how to escalate concerns to the appropriate authorities or safeguarding leads within the organisation. Staff understanding of safeguarding was discussed in staff meeting and supervisions.

Staff told us that they were provided with thorough safeguarding training upon induction and through ongoing professional development sessions. This training covered recognising signs of abuse, understanding the different type of abuse, and the correct protocols to follow if concerns arose. One staff member said, “I hold a level 3 safeguarding certificate. This training covered a range of areas that we need to be aware of, which includes how to identify the signs of abuse and when and how to report concerns”. Another staff member told us, “I have completed safeguarding training as part of my induction and through regular refresher courses. This helps me stay confident in recognising and reporting any safeguarding concerns.”

People we spoke to told us that information about safeguarding was also made available to people using the service and their families. People told us they felt safe when being supported by staff. One person said, “The communication is really good, this is with the staff and the manager. I feel safe with the staff who supports me”.

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’s risks were safely managed. Risk assessments involved identifying potential risks and evaluating the likelihood and impact of those risks on each person’s daily life. By engaging both people and their families in these discussions, the service ensured that the assessments were thorough and reflected the unique circumstances and preferences of each person.

For example, this included risks relating to falls and trip hazards. Such risks might arise from uneven flooring, loose cables, poorly lit walkways, or cluttered areas, which can all increase the likelihood of someone tripping or losing their balance.

Staff told us that they were involved in completing risk assessments. One staff said, “I write risk assessment with the person I’m supporting. I then send the risk assessment to my line manager to review.”

Care plans were then developed based on the outcomes of these risk assessments. People and their relatives told us they contributed to risk assessment regarding their loved one’s needs and routines. One person said, “I was involved with the completion of risk assessment and with my care plan too.” A relative told us, “I am fully involved with my loved one’s risk assessments and care package, as I advocate for them.”

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

Prior to the service delivering support, comprehensive assessments were conducted on people’s properties. These assessments identify potential hazards and ensure that appropriate strategies were put in place to minimise risks. The process is designed to create a safe environment for everyone involved, allowing staff to carry out their duties effectively while safeguarding the people they supported.

People told us, staff supported them safely. One person said, “Staff are clear on how I like to be supported. The staff will talk to me about any concerns that they may have identified so we can address it together.

Staff stated that the provider carried out risk assessments of people’s living environments, which contributed to the safety of both staff and those receiving care.

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 received key training across a number of areas to ensure they could support people effectively and maintain safety. This training covered safeguarding adults and children, infection control, risk assessment, and approaches to supporting people’s mental health and managing anxiety.

The provider had systems in place to carry out relevant pre- employment checks before staff worked at the service. Staff files contained application forms, copies of passport or driving licence, references, health checks and criminal records checks. This helped to ensure people who used the service were not exposed to staff that were barred from caring for vulnerable people.

Staff confirmed that they had received an induction when they started working at the service. We also saw evidence of completed induction forms. This covered a number of areas including training and familiarising themselves with policies and procedures and getting to know people who used the service.

One staff told us, “When I first started working for the service, I was given an induction, and I shadowed an experienced member staff who had worked for the organisation for some time.”

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.

Staff received training on infection prevention and control (IPC), and people told us that staff consistently wore personal protective equipment (PPE) and assisted in maintaining the cleanliness and tidiness of their homes. One staff member told us, “We are given PPE such as gloves, masks, and aprons, which is always available and used as required to maintain infection control.”

The provider conducted infection control audits to observe and assess staff performance, ensuring that appropriate infection prevention and control measures were consistently implemented during daily routines.

A relative said, “The service ensures that staff have enough PPE, and they carry out spot checks to ensure staff are using it correctly.”

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.

Staff were trained and had their competency assessed prior to administering medicines to people. One staff member told us, “I administer medication and have received full training. If a mistake occurred, I would report it immediately to my line manager, record it accurately, and follow the medication error policy to ensure the individual’s safety.”

People and relatives told us they received their medicines as prescribed. One person said, “Staff know how to help me with my medications, I had no issues or concerns.” A relative told us, “Before staff can give medication, a manager has to assess them to ensure, they know what they are doing.”

Management conducted daily, weekly and monthly audits. Audits identified concerns regarding gaps in people’s Medicines Administration Records (MAR), where staff had not completed the MAR accurately. It was observed that actions were recorded in the audit documentation, and staff were provided with refresher training as a result of these findings. Additionally, any concerns identified were addressed in accordance with the provider’s staff performance procedures.

During our assessment we reviewed Peoples MAR records which we observed staff had completed correctly. All entries were appropriately documented, demonstrating adherence to established protocols and ensuring the accuracy and safety of medication administration.

The registered manager explained that they consistently oversaw staff members' practices in relation to administering medicines to people and would take appropriate actions where required.