Crown Mews

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 69 (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 did not have a consistently proactive and positive culture of safety based on openness and honesty. Staff had not historically reported safety events appropriately, which meant opportunities for learning had been missed. The provider acknowledged this and demonstrated a commitment to making improvements to how accidents, incidents, concerns, and safeguarding referrals were monitored and responded to. Recent concerns had been managed appropriately. Staff told us they were well supported by the management team and confirmed they had opportunities to reflect following incidents. However, processes were still being established and embedded to enable the service to effectively sustain a culture of organisational learning and continuous improvement.

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 carried out assessments of people’s needs before they started receiving support. Information gathered during these assessments was used to develop care plans, which guided staff on how to provide care safely and in line with people’s individual needs and preferences. Staff told us they referred to these plans when delivering care. Staff worked well alongside various professionals to ensure people received appropriate support, in line with their needs.

The provider did not consistently work with people and their relatives to understand what being safe meant to them and the best way to achieve that. Some relatives expressed concerns. One relative told us, “I do wonder what goes on behind closed doors.” Another family member told us, “Are staff kind? I’m not sure about behind closed doors.” While no one directly reported that their family member was unsafe, one person described “a sense of mutual distrust” between themselves and staff. The management team acknowledged the concerns raised and recognised the need to strengthen relationships with family members. They told us they were committed to improving communication and building trust as part of an ongoing programme of cultural improvement. However, this work was ongoing at the time of our assessment. Staff were trained in safeguarding and understood the procedures in place to keep people safe. Professionals also provided us with positive feedback and told us care they observed was safe.

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. Care plans and risk assessments reflected individual preferences and promoted positive risk-taking, supporting people to maintain their independence at home, in the community, and when taking part in activities. Risks associated with people’s health were known and managed. Detailed positive behavioural support plans were in place and staff told us this guidance enabled them to support people safely. Staff used active support approaches to help people develop their skills and confidence and the professionals we spoke with gave positive feedback in relation to this.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Records demonstrated this and people confirmed that. For example, the provider had risk assessed people’s home environments to help keep people, and staff, safe including in relation to fire. They also had introduced additional checks in response to potential risk, for example, where a person was known to the damage window restrictors in situ.

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. We found staff had been recruited safely and they reported receiving an appropriate induction to the service. Staff also told us they had undertaken training relevant to their roles, which supported them in meeting people’s needs effectively. However, some relatives expressed concerns regarding the adequacy of staff training. One relative commented, “I’m not aware of what training staff have, but they don’t appear to have the right training for [family member].” This view was echoed by a professional, who stated, “It is recommended that staff receive additional training regarding specific conditions and the adaptation of communication strategies.” We raised these concerns with the management team, who confirmed they were working in partnership with external professionals to further develop staff skills and training; this work was ongoing at the time of our assessment.

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 confirmed that they had enough Personal Protective Equipment (PPE) available to them and had completed infection prevention and control training. No concerns were raised by relatives or professionals regarding infection prevention and control.

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. Records confirmed medicines were administered as prescribed and followed good practice guidance. Staff has received training in managing and administering medicines and had their competency to do so assessed. There were effective systems and processes in place to audit and review medicines management. Staff understood their responsibilities for reporting and managing medication errors.