Jane House

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 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 72 (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. Accidents and incidents were analysed but not frequently enough to identify current trends and patterns. We discussed this with the registered manager, and they took action to make improvements. This approach needed to be sustained and embedded into practice. This was discussed with registered manager, and they agreed to take action.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. People had hospital passports in place with ensured continuity of care was maintained when they moved between services. Members of staff had good access to information about people and were able to share this with health and care professionals when required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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 made appropriate referrals to the local authority to keep people safe. We discussed submitting notifications to CQC at the same time these referrals were made and the registered manager identified improvements to their reporting processes. There were safeguarding policies in place and staff had good knowledge about how to keep people safe. A member of staff told us, “I have access to safeguarding policies and I am familiar with them. If I suspected abuse I would take it seriously and would report it immediately and act in line with safeguarding procedures. I would ensure the individual is safe and not in any immediate danger and I would then report my concerns to the safeguarding lead as soon as possible following the correct reporting process.”

We saw evidence the provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care plans were personalised and clearly identified their needs. Risks were identified and mitigated in the least restrictive way which enabled people to live their lives they way they wanted. We observed care and support being delivered in line with people’s care plans.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider ensured the environment enabled people to receive care and support safely. The provider carried out regular checks and reviews of key aspects of the care environment including fire safety, water temperatures and gas safety which ensured the care home was safe.

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 which met people’s individual needs. The provider had appropriate and detailed risk assessments in place which identified the numbers of staff required to support people throughout the day. Risk assessments were reviewed regularly which ensured the appropriate staffing levels where in place. People had access to members of staff when they went out and when they engaged in activities. Where people needed more intensive support, appropriate levels of staffing were in place. Members of staff were recruited safely and the provider carried out pre-employment checks in line with their policies and processes.

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 care environment was clean, tidy and well-presented. Personal protective equipment (PPE) was available for members of staff to use when providing personal care. A member of staff told us, “We complete infection control training and this is refreshed every 3 years. Observational checks are carried about by the registered manager to ensure we are using PPE correctly.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medication administration was managed safely and people received their medications as prescribed. Regular audits and stock checks were completed by a member of the management team. There was no evidence of over-medication or inappropriate use of medication. A member of staff told us, “I receive training in safe handling of medications and this is refreshed every 2 years. Staff are also assessed every 6 months by the registered manager. If a medication error was to occur, I would record and report it as soon as possible and if needed I would seek urgent medical advice.”