Gray Healthcare

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• 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

The rating for the safe domain in the previous inspection was good. After this assessment the rating remains good.

The clients we spoke to all said that they felt safe in their respective homes, and that the staff who cared for them were caring; one client said that he did not feel that his care team could be improved.

Staff were asked about their knowledge of safeguarding procedures, and all staff interviewed had a full understanding of these procedures and what constituted the grounds for a safeguarding referral.

The service had a safeguarding process map for the management of safeguarding concerns. The map outlined the steps to be taken in the event of a safeguarding incident, including whether a safeguarding threshold had been met, the relevant authorities to refer the safeguarding matter to, where it was logged for reference, investigation tasks if relevant, and the final processes to review the incident and the correct closure procedure.

Safeguarding training was fully compliant, with intercollegiate training levels applied to each staff member, depending on their role within the service.

The clients we spoke to felt that they had taken an active part in their risk assessment, including the formulation of positive behavioural support plans. They all stated that they felt safe, and that staff looked after them appropriately.

We were told that carers were fully involved in the monitoring of the care received by relatives, including a social media app for parents and carers where information was shared.

Staff told us that they involved people in their care as much as they could regarding management of risk. In recent years, staff at the service have been considered for national learning disability and autism awards for their hard work in this field, and this has been recognised in the work to minimise risk and maximise involvement at the service.

The clients we spoke to said that there were enough staff at each location, and that changes in staff would always be reported to clients if possible.

The registered manager told us that staffing was led by a front-end assessment that indicated the number of staff each client would need, whilst also taking into account the opinion of the client.

Staff told us they felt their current team was experienced and well-trained, with a good skill set. Clients with learning disability and/or autism had staff who had additional training.

Staff training in treatment of clients with autism and learning disabilities was stressed at the service, ensuring a comprehensive action and care plan was in place for those who required it.

Clients told us that they were happy living in their own homes, it was beneficial to their well being and mental health.

Staff told us that environmental safety was a core factor during multidisciplinary team meetings, and that safety at home was key. We saw minutes from professionals’ meetings that clearly showed actions taken when environmental concerns were raised at locations.

Autistic and learning disability clients with sensory needs had adjustments built into their care plan and environments, as well as staffing considerations.

We saw a case study regarding the progress of a client who had many sensory needs when accepted by the service, we saw how the service had obtained a relevant property and had made adaptations to include sensory considerations resulting in a positive outcome for the client.

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.

Clients we spoke to told us that they felt safe, that the service responded accordingly when they raised issues. Client opinions were positive regarding the way in which their care and treatment was provided. There were multi-disciplinary meeting minutes that involved the clients, showing that questions raised or points made were noted and acted upon.

The service had a Lessons Learned Committee that met regularly, where care, incidents, investigations, complaints and safeguarding issues were fully discussed and appropriate actions taken. The minutes from the meeting in October 2024 showed how the meeting followed a recognised reflective cycle process. This included various feedback avenues, what worked well and what did not work well, a full evaluation of a given situation, a conclusion, an action plan, and a summary of the findings that could be used as an overview.

Staff told us that they received relevant findings from incidents in team meetings, it was a standard agenda item, and they felt fully informed. The registered manager operated an open-door policy that encouraged staff to come forward with any problems they may have encountered at the service. One to one meeting processes were in place and adhered to, allowing for open and frank discussion.

Staff knew the policy regarding duty of candour and the necessity of being open and honest with clients and their carers in the event of an incident taking place.

We reviewed care records of clients at the service and noted a comprehensive consideration of a client's history of treatment and risk, and how action plans and care plans were formulated to take into account the possibility of extra trauma that might impact on the client during a transition to the service. We saw that environmental, staffing and property concerns were considered and routinely re-visited to ensure that clients continued to be treated to a high standard.

The service had a position paper on trauma-informed care from December 2024, The approach sought to avoid re-traumatisation through six core principles: safety, trustworthiness, choice, collaboration, empowerment, and cultural consideration (*inclusivity"). Trauma-informed care was reflected in the work of the service and its approach to assisting clients to move forward.

Policies and procedures were in place to protect clients from harassment and discrimination, and the clients we spoke to did not raise any such concerns. The service ran workshops for staff to identify different types of abuse.

The service had regular contact with safeguarding teams and the local authority, and this was reflected in meeting minutes and in contact with partners.

The clients we spoke to all said that they felt safe in their respective homes, and that the staff who cared for them were caring; one client said that he did not feel that his care team could be improved. Clients told us about holidays away with staff and trips out, all positive. None of the clients nor the carer we interviewed had made complaints about the service, they felt the service was working in a positive way for the clients in their care.

Due to the nature of the service, staff who were caring directly for clients in the community were contacted and interviewed remotely, whilst staff who worked at the head office of the service were interviewed in person.

Staff were asked about their knowledge of safeguarding procedures, and all staff interviewed had a full understanding of these procedures and what constituted the grounds for a safeguarding referral. We were told of the individual requirements for each client to ensure that safety was paramount, including assessments where smoking was a considered risk, and how they created as safe an environment as possible for each client.

We were told that often a rise in safeguarding incidents would occur when a new staff member or a team was disrupted, possibly by a long period of leave or a staff member leaving the service, and a new staff member being accepted by the client. These would settle down as the client and the staff member bonded.

We contacted commissioners and requested their feedback regarding the safety aspect of client care and were given positive responses. Responses showed that the safety and care of the clients was deemed to be good, although there were some concerns about manager turnover and the possible effects that changes to management structure might lead to limited support for staff and clients. There were no safeguarding issues raised.

The service had a safeguarding process map for the management of safeguarding concerns. The map outlined the steps to be taken in the event of a safeguarding incident, including whether a safeguarding threshold had been met, the relevant authorities to refer the safeguarding matter to, where it was logged for reference, investigation tasks if relevant, and the final processes to review the incident and the correct closure procedure.

The service had a full safeguarding policy and procedure (CR100) that was reviewed regularly, was in date, and outlined the relevant protocols and procedures in handling safeguarding issues. The policy included key lines of enquiry as it related to the Health and Social Care Act, and a comprehensive list of relevant legislation and underpinning guidance and knowledge. A safeguarding steering group met bi-monthly to discuss safeguarding issues and the results of actions relating to those issues.

Minutes from a professionals meeting in December 2024 outlined some concerns regarding repairs need to a client home, and the safeguarding aspect was fully considered and acted upon. This included actions that included the Integrated Care Board in decision making.

Safeguarding training was fully compliant, with intercollegiate training levels applied to each staff member, depending on their role within the service. Staff with the role of safeguarding investigations had relevant certificates of continuing professional development from an external source showing the level of training achieved and skill set in investigating safeguarding issues.

The service followed an established safeguarding model that easily identified directions to enhance and ensure a solid investigation. There was guidance for the taking of photographs of injuries to clients or staff if deemed necessary during an investigation.

The service had a safeguarding focus group, we reviewed the minutes of the November meeting of the group. The minutes included input and output sources, as well as performance indicators for quality improvement. There was also a safeguarding steering group at the service, we reviewed minutes of the December meeting and saw that the service reviewed any new safeguarding incidents (there had been two incidents for consideration) outlining the incidents, what happened, and how they could best be avoided going forward.

For the month of December 2024, prior to our inspection, there had been only one safeguarding incident at the service.

Records of care relating to individual clients indicated that, generally, outcomes for clients were favourable, with improvements relative to the care that was received. We were told that one client had significantly improved since the service had taken over their care, and this was reflected in lower incidents of aggression, self-harm, and other traits that had been prevalent prior to their care package being placed. Safeguarding incidents had markedly reduced, and this was reflected in the minutes of multi-disciplinary team meetings and audits.

The clients we spoke to felt that they had taken an active part in their risk assessment, including the formulation of positive behavioural support plans. They all stated that they felt safe, and that staff looked after them appropriately. One client was concerned that we were going to impact on her care by asking such questions and was fully assured that this was not our intention.

We were told that carers were fully involved in the monitoring of the care received by relatives, including a social media app for parents and carers where information was shared. We were informed that any information required was available, and that carers would not hesitate to contact the service if they felt the need to do so. A weekly meeting included carers and gave opportunities for carers to fully explore the ongoing care of their relatives.

Due to the nature of the service, and the wide geographical spread of the locations where clients were situated, we did not observe active involvement of clients in the management of their risks. However, in view of the positive comments from clients regarding their involvement when interviewed, coupled with the views of carers when discussing team involvement with their relatives and availability should a problem arise, as well as the care records reviewed, this would indicate that there were limited identifiable problems to be noted.

The inclusion of clients in the management of risks was clear and present in our assessment of the service. Care records and multi-disciplinary team minutes showed that the service worked hard to include clients and carers, as well as stakeholders. The turnover of locality management was felt to impact on clients, but it was agreed that currently those managers present were appreciated and effective in their roles.

The service had a restrictive practice including restraint policy and procedure (CR77) in place, the policy was up to date. The policy comprehensively outlined the need to involve clients in their risk management, stating various factors to be considered, such as capacity to understand, and how to solve factors, such as the use of independent mental health advocates and ensuring carer involvement. The policy stressed the need to ensure that all aspects of involvement (or lack of) were recorded and considered.

The service had a pilot programme in place that created a pictorial display that was relevant to each client and that outlined different aspects of client competency including communication skills, social activities that could be beneficial to the client, cognitive skills, clinical aspects and community interaction levels. Each aspect was in the first person, and clients were included in the creation of these displays, and levels of interaction or relevance were measured simply by the use of a five-star display, one star showing no interest or unable to complete an action, and five stars if the client could complete a process fully. The service also had a screening tool that was completed with the client to more fully investigate their willingness to try new things or do things for themselves.

The service also used simple flash cards that clients could use to show the mood they were in, or if they considered a particular support worker as good or shouts, indicating trust levels with particular staff. These could be noted and used should a change or rotation in staff was required in the best interests of the client.

The service used a sensory processing measure tool that ensured that clients were able to give input regarding external factors that might affect them, such as bright light (vision), hearing, taste and smell and balance and motion. There was also a “widgit” pictorial story that could be used, such as a story showing how dangerous a radiator could be due to heat, or being pulled off a wall, the story relating to someone who had done this and learned a lesson. This story board could be altered to adapt to other circumstances, such as how weather cannot be controlled or how to ask for a radio station to be turned on.

Care records that we viewed showed that client involvement was sought by the service, and most clients were keen to give their opinions as to how they should be involved in decisions relating to their care.

We discussed involvement of people in managing risks with staff. The registered manager informed us there were no clients at the service who required the use of rapid tranquilisation as part of their care plan, the service would not take on clients with this high level of risk. We were told that all staff were trained in management of violence and aggression, and that the service used a well-formulated external training resource that concentrated on minimising the use of physical interventions and to emphasise sound behavioural support strategies based upon individual needs, characteristics and preferences. We reviewed the resource and noted that it met the needs of the client base at the heart of the service. The service monitored the use of restrictive practice on a weekly basis, acting accordingly when required.

In order to ensure that staff identified client communication needs, communication preferences were noted and put into care plans, risk plans and positive behavioural support plans. We reviewed care records of clients at the service and this was noted. The use of ‘talking mats’ (a visual tool that allows Velcro pictures and symbols to be placed on the mat to improve and ease communication) was available, as well as easy read procedures.

Staff told us they involved people in their care as much as they could regarding management of risk. In recent years, staff at the service have been considered for national learning disability and autism awards for their hard work in this field, and this has been recognised in the work to minimise risk and maximise involvement at the service.

Staff told us that physical restraint was avoided, if at all possible, but that it depended upon the client as to the frequency of use. Each client had an audit-based intervention checklist that outlined the type of ‘command stance’ to take with each client, whether to be strong in reacting to a behavioural problem and the type of restraint that would work best for the client, such as front approach prevention and one-arm catch, to let the client see the staff member and the type of restraint deemed most effective.

Clients told us they were happy living in their own homes, it was beneficial to their wellbeing and mental health. One client said a benefit of living in his own home was that his carers could take him to places he liked to visit. The client stated that they felt safe in their home, and this sentiment was repeated by other clients.

None of the clients we spoke to raised concerns about their homes. A carer told us that the property their relative was in was under review to move to a better property, but nothing raised about the safety of the location.

Due to the nature of the service, and the wide geographical spread of the locations where clients were situated, we did not observe active involvement of clients in their homes and any ongoing environmental concerns. Documents provided by the service showed that any environmental concerns raised were dealt with as quickly as possible, and that those involved in dealing with repairs and maintenance of the homes were fully versed in client safety.

We reviewed our findings regarding outcomes and safe environments. Although there were no visits to the homes of the clients at the service, clients told us that they felt safe, carers were happy with locations and the work done to maintain them. Staff told us that any environmental concerns would be raised immediately, and the service provided us with audited documentation to show that properties were being monitored and maintained with full consideration of the needs of the client in mind.

The service used environmental assessment and risk mitigation plans for clients to ensure that properties that were housing their clients met needs and safety concerns. Plans included a review of identified risks (including ligature points, potential hazards), a full breakdown of each room in the environment (including risks and how improvements were either needed or would be of benefit to the client, whether redecoration was required), external factors such as a garden whether shared or private, and the surrounding area. We saw examples of these plans, they were comprehensive. Support plans for clients showed that space for wheelchairs or other equipment was factored into the location.

We saw minutes of planning meetings where there was discussion about repairs and suitability of locations for clients. One set of minutes considered the best way to possibly relocate a client for a short period whilst some important repair work was completed, due to the knowledge that the client would not be able to cope with the intrusion. The minutes were comprehensive, and full consideration was given to the client and their inclusion in decision-making.

We saw a case study regarding the progress of a client who had many sensory needs when accepted by the service, we saw how the service had obtained a relevant property and had made adaptations to include sensory considerations resulting in a positive outcome for the client.

Staff told us that environmental safety was a core factor during multidisciplinary team meetings, and that safety at home was key. We saw minutes from professionals’ meetings that clearly showed actions taken when environmental concerns were raised at locations. Site visits were regularly carried out, and even more so if damage had been caused by a client when unsettled.

We were told, and subsequently shown, that when building work needed to be completed, an anonymised “pen portrait” of the client at the location could be made available to builders outlining the personality of the client, and how best to deal with any issues that might arise. The service appeared quick to deal with issues relating to safe environments, and staff told us that they could and did report any failings as quickly as possible to ensure quick action.

Autistic and learning disability clients with sensory needs had adjustments built into their care plan and environments, as well as staffing considerations. Staff were trained in National Early Warning System (NEWS 2) and were aware of the initial assessment recommendations for each client, with specific health action plans in place in line with the Learning Disability Mortality Review (LeDeR) programme. Staff we spoke to knew about the programme, and the registered manager stated that there had been no deaths at the service that required LeDeR notification.

The clinical strategy at the service meant that each client had a completely individualised treatment plan, due to the nature of the service. Care plans were underpinned by a recognised clinical risk assessment and management tool at two levels.

We spoke with commissioners who raised no concerns about the environmental aspects of client homes. We were told that their clients were receiving good, safe care.

The clients we spoke to said that there were enough staff at each location, and that changes in staff would always be reported to clients if possible. One client told us that her main staff carer would ensure that if they were going on leave the client would know well in advance and be informed of which staff member would be replacing them in the interim.

A carer told us that there were no problems with the number of staff for their relative, but because the area where the client was located was quite rural, staff need to be able to drive to be with their relative. This also allowed for their relative to be given opportunities to travel outside of their home. We were told that senior carers would also make drop-in calls just to make sure everything was all right.

Due to the nature of the service, and the wide geographical spread of the locations where clients were situated, we did not observe active involvement of clients in their homes and the staffing that they had in place at the time of the assessment. However, comments from clients about their staff did not indicate any shortfall in staffing numbers or the experience of staff. Agency staff were mentioned as occasional replacements, but from the experience of clients we spoke to this did not seem to create any problem for the client.

It was clear from the information from clients, carers and stakeholders, that staffing was deemed an essential aspect of care for the clients especially regarding the necessity of solid relationships between staff and clients. Clients told us that they were happy with their staff teams, and this was reflected in their comments and views. Carers were happy now that the senior locality managers were more stable, they felt it helped to have someone close by to act in an emergency.

Commissioners were provided with regular reports regarding their clients, these included all aspect of care including staffing recommendations, with commissioners having the right to respond. The reports we reviewed showed a comprehensive breakdown of the client at the time of the report. Commissioners we spoke to said that they were more concerned about the logistical side of the service than the care their clients were receiving as it related to locality managers and their base locations. One commissioner told us that one of their clients was leading a much-improved life since joining the service.

We spoke to commissioners and were informed that staffing had not been a problem with their clients, but they did raise the issue of staff turnover making it difficult for clients to adapt after they had become used to a particular staff member or manager. One commissioner said that their client had a lot of managers, but there is currently a manager who has been in place for a while, albeit they do not live locally. The commissioner stated that the service had recently employed a new manager who would be taking over, and who lived closer to the client, and they felt this would benefit their client.

The service had a computer system that included a rostering tool that ensured that shifts were covered, and any shortfall was flagged. The system also had a skill-based scheduling facility that ensures that relevant staff are appointed accordingly.

We looked at staffing rotas for a three-month period leading up to the assessment. Rotas were broken down into not just who was working when and where, it also included information about who is working on a ‘waking night’ (where staff member has to remain awake for the night shift), floating shifts, and all other aspects that might be included such as clinical training hours.

We were provided with the rotas for three clients to review over a three-month period. The rotas showed the staff members who would care for a particular patient, including their contracted hours. The rotas were easy to audit, and we were also given copies of staff sickness summary rates and staff absence reports. The sickness data updated to January 2025 showed that there were only two staff on long term sickness leave, and other sickness figures were well within acceptable limits for the size of the service. The sickness data from October 2024 to December 2024 was also audited and clearly outlined in the computer system used by the service.

Bank and agency staff were utilised, this was monitored and audited. The service ensured that the staff used were known to the clients. We saw the evidence of audit of use of bank and agency staff and noted that a process map was in place in order to ensure that due diligence was followed in the use of bank and agency staff.

The service had a probation review system for all new staff, as part of their induction. These were completed at regular intervals and allowed managers to ensure that aims were being achieved, and that progression was in place, as well as identifying any points of improvement that could be considered.

Staff training in treatment of clients with autism and learning disabilities was stressed at the service, ensuring a comprehensive action and care plan was in place for those who required it. This included e-learning and practical assessments, the level of training commensurate with a good understanding of the subject, as well as an on-going working policy with a local autism well being project in Liverpool. The initial assessment of the clients was used to identify clients with these characteristics, and clinical confirmation would follow.

The registered manager told us that staffing was led by a front-end assessment that indicated the number of staff each client would need, whilst also taking into account the opinion of the client. Minimum staffing for clients over a 24-hour period would be one staff member to one client, this being the minimum that would or could be provided. Client needs drove levels of staffing for each 24-hour period.

We were told that one to one time for each client with a staff member was a collaborative approach, considering the view of the client and the number of the clinical commissioning hours allocated to that client. Client willingness to interact would always be the driver as to how successful any one-to-one interaction would be.

Medical cover was provided in the first instance by emergency services, should the circumstances require that level of input. Staff members were all trained in recognising and applying national early warning scores (NEWS) and baseline observations. Staff have also received level four and five safeguarding training.

Staff told us they felt their current team was experienced and well-trained, with a good skill set. Clients with learning disability and/or autism had staff who had additional training. There was external training and support from landlords and fire officers regarding fire systems and accessing electrical, gas and water shut-off locations in each home. Some clients will not engage when systems are being tested, refusing to follow evacuation protocols, and this is reported as a safeguarding issue.

We were told that inadequate staffing was very rare at the service. Staff described how they handled incidents such as ligature use (the use of an item to restrict breathing and/or blood flow with the aim of self-harm) and threats of suicide. Staff told us that protocols were in place that were strictly followed to ensure the safety of clients and staff. We were told that senior staff could always be contacted for advice in the event of an emergency or for input into a situation.

Staff told us that they felt the training was adequate, both online training and face to face. The staff we spoke to said they were fully up to date with their mandatory training.

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

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