Archived: The Leys

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 66 (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. Staff documented incidents and accidents, and leaders reviewed this information to determine whether lessons could be learnt, and changes could be made to reduce recurrence. A relative said, “I trust them implicitly and know they’ll do what’s best for my [Relative].”

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Records evidenced people had been supported to access external health professionals such as GPs appropriately and when needed.
 

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 relatives we spoke with, did not have any safeguarding concerns. Staff had received safeguarding training and knew who they could report concerns to externally if needed. A person told us, “I am safe.”

A person’s care plan did not contain guidance from a health professional about how their food should be prepared safely. In response to our feedback, the provider told us they would update the person’s care plan.

However, other risks such as how people needed to be supported outdoors, food preparation and medicines had been assessed and planned for. Staff were knowledgeable about risks people could experience and could tell us how they supported people’s safety
 

We observed that some improvements were needed to environmental safety and suitability. For example, we observed 2 fire doors did not fully close into the frame, increasing fire-related risks. A hot water outlet in a person’s bedroom had very little flow. In response, the operations manager informed us they had referred this to the provider to arrange for repair or maintenance. Although not directly affecting people’s safety, some parts of the service appeared worn and tired, such as the flooring, seating, and some fittings. A staff member told us, “The place is very tired and could do with some updating.” However, communal bathrooms had been recently refurbished.

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 were recruited safely. Staff schedules showed enough staff were deployed. All relatives felt there were enough staff. A relative said, “What I do think is, there’s a fine balance between quantity and quality and the quality of the staff is great.”

Some worn fixtures and furnishings in areas such as bathrooms and flooring did not promote good infection prevention and control and increased risks of harbouring germs. Additionally, we found that a communal freezer and some areas of flooring were unclean. However, overall, the service was tidy and free from malodour.

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. We observed that medicines were stored safely in people’s bedrooms. This also promoted their privacy. Protocols for medicines which people took on an as-needed basis, such as pain killers, were person-centred.