Drs Adey and Dancy

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

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service ensured that equipment, facilities and technology supported the delivery of safe care but did not always detect and control potential risks in the care environment effectively.

The service had contracts in place to maintain the premises. Staff and leaders completed health and safety risk assessments and undertook audits; however, these were not always effective in ensuring that all risks were consistently identified and addressed. For example, risk assessments had been completed but were not always readily accessible, and actions identified were not consistently tracked and followed through. Following our assessment, the provider submitted evidence demonstrating that action has been taken to resolve this concern.

The service had a business continuity plan, which was regularly reviewed and outlined how the service would continue to operate in the event of a disruption.

The service ensured there were sufficient qualified, skilled, and experienced staff who received support, supervision, and development. Staff worked well together to provide care that met people’s individual needs; however, systems were not always effective in retaining appropriate evidence and ensuring follow-up actions were completed.

Leaders had systems in place to monitor mandatory training and ensure staff worked within their areas of competence, and these were effective in ensuring training was completed.

The service did not always follow safe recruitment procedures when employing staff, in line with national legislation. Of the recruitment files sampled, we found some areas where records were not fully complete, including retaining evidence of registration checks. In addition, not all required documentation was consistently available, including photographic identification, proof of qualifications, and right to work checks.

Following our assessment, the provider submitted evidence demonstrating that action has been taken to resolve these concerns.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. Staff had completed infection prevention and control training; however, the infection prevention and control lead had not undertaken training appropriate to this role. We discussed this with the provider who wasreceptive to our feedback and provided assurance that this would be addressed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.