St Anne's Leeds Domiciliary Care 3 (DCA3)

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 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.

Incidents, accidents and safeguarding concerns were reported, reviewed and used to promote safer care. Records showed that incidents were managed appropriately.

Staff told us they knew how to report concerns and were knowledgeable about the providers processes for reporting incidents and safeguarding. Managers shared learning through meetings, supervision and day‑to‑day communication.

Managers followed the Duty of Candour when things went wrong. They issued apology letters, reviewed complaint documentation and shared outcomes with staff. They also notified external professionals, and kept families informed. This transparent approach helped maintain trust and improved how concerns were identified and resolved.

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.

Managers assessed people’s care and treatment needs before accepting them into the service. This ensured the provider could meet people’s needs and prepare for a safe and well‑planned transition. Managers arranged pre‑admission visits where required and involved people, families, external professionals and staff in transition planning.

Staff acted promptly to make referrals to external professionals and to arrange health appointments. They recorded referrals, supported people to attend appointments where necessary, and made reasonable adjustments in line with the Equality Act 2010. These actions ensured people received timely access to appropriate professional 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.

The provider had a safeguarding log which had recently transitioned from an Excel spreadsheet to the electronic care system, Nourish, improving oversight and consistency of recording. The provider shared concerns quickly and appropriately.

The provider had a clear safeguarding policy and staff understood their responsibilities to safeguard people in their care and were familiar with whistle blowing policies. A staff member told us, “Safeguarding is what we use to protect people from abuse. We report to the safeguarding team and manager.” We asked people if they felt safe whilst receiving a service from St Anne's Leeds Domiciliary Care 3 (DCA3). People said, “Yes, I feel safe” and “I can always go to the area manager if I needed to speak to someone.”

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.

Risks were clearly identified through personalised risk assessments, positive behaviour support plans and regular reviews, all of which were detailed, up to date and tailored to individual needs. Staff consistently followed clear guidance on managing risks relating to health, behaviours of concern, finances, medication, independence and community access, ensuring people were supported to take positive, proportionate risks while remaining safe. A person said, “Staff help me with my money and shopping. Staff help me to cook my food.”

The provider balanced risk with promoting independence, supporting people to develop life skills such as cooking, managing money and travelling independently, with clear guidance in place should risks increase. For example, 1 person had a desired outcome to ride a scooter, the staff explained the risks of this with the person, and it was agreed they would wear protective equipment for their safety prior to carrying out the person’s wishes to do this activity.

Staff demonstrated good understanding of individual triggers, early warning signs and de‑escalation techniques, helping to prevent harm and promote wellbeing. For example, 1 staff member told us how a person’s epilepsy was managed and how the risks were mitigated safely to prevent further health complications.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Systems and processes were in place to support people to maintain a safe and pleasant home where risks were identified and managed alongside the person’s needs. Staff took appropriate action when environmental risks were identified. For instance, broken glass was found in a person’s bedroom and was promptly removed without any injury occurring.

A case study we reviewed showed clear evidence of how staff supported an individual to create a safe living environment and promote their overall wellbeing. The person shared their experience with us stating, “My room was in a mess for quite some time, and I began hoarding. Every corner was filled with belongings. I eventually moved everything into a storage unit, which allowed me to fully declutter my room. I was then able to have it redecorated — I finally got the Tartan carpet I’d always wanted, along with brand‑new furniture. Now I can relax in bed and watch TV, and I even have a new television that I couldn’t have had before.”

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.

The registered manager ensured there were adequate staff employed to meet people’s needs and ensure continuity. Safe recruitment practices were in place to ensure suitable staff were employed. Recruitment of staff was done safely and included relevant checks such as Disclosure and Barring Service (DBS) checks. DBS checks help providers assess the suitability of individuals for roles, particularly those involving vulnerable people. New staff completed a full induction process as well as completion of their mandatory training and competency checks to ensure they had the knowledge and skills to undertake their duties.

Staff told us they were given enough time to spend with people. A staff member said, “Generally, we have enough time to do activities with people. I would say we have a good team.” People said staff were friendly and supported them with their needs. Comments included, “Staff are nice, very friendly” and “The staff are great.”

Most training compliance levels were high, including safeguarding, medication, Positive Behaviour Support (PBS), de‑escalation and specialist training tailored to individuals’ needs, such as seizure awareness and mental health.

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.

The provider demonstrated effective infection prevention and control arrangements across the service. Adequate supplies of PPE were readily available, and staff were able to describe when and how PPE should be used, including during personal care and when exposed to bodily fluids. Staff received infection control training and showed a clear understanding of hygiene practices, helping to reduce the risk of the spread of infection.

Regular audits were completed as part of the manager’s monthly checks, including cleaning standards, control of substances hazardous to health, waste management and equipment, with no significant issues identified. Environmental cleanliness was maintained, with appropriate procedures in place for managing spills and maintaining shared areas safely.

Infection risks were considered within individual care plans and risk assessments, including safe food handling, personal care support and medication administration.

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.

Medicines were managed safely, with robust systems in place to reduce risk and ensure people received their medicines as prescribed. Clear medication policies were available, including PRN protocols. Medicines were stored securely, with daily stock checks completed and regular audits carried out to monitor accuracy and compliance.

MAR charts were consistently completed, with medicines signed for appropriately and clear recording of administration times, doses and reasons for PRN medicines. Where recording errors or omissions were identified through audits, these were promptly addressed through supervision and performance discussions, demonstrating effective management oversight and learning.

People were supported in line with their assessed capacity. Some individuals safely self‑administered medicines with agreed levels of staff support, while others received full assistance, in line with MCA assessments and best‑interest decisions. Easy‑read medication information was available to promote understanding and involvement.