Greenways

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 Inadequate. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the provider had a proactive and positive culture of safety and staff listened to concerns and reported safety events, lessons were not always learnt or investigated to continually identify and embed good practice.

Accidents and incidents were appropriately logged. However, records sometimes lacked detail about the reasons for increased behaviours or the discussion that led to actions. We found the same actions were repeated in all 4 reviews for 2 people, despite reported increases in behaviour. This indicated a lack of effective review and learning from what was and was not working well for the person to reduce risk.Following our assessment, the registered manager informed us, “We acknowledge the feedback regarding limited detail in some meeting records. To strengthen our documentation, we are revising our templates to include prompts for more comprehensive narrative recording and clearer rationales for all decisions made. Moving forward, we will take detailed minutes to ensure that discussions, actions, and learning outcomes are fully captured.”

There was also a whole provider approach to learning lessons, so that incidents that had occurred in 1 of the provider’s services could be prevented in others. The quality manager confirmed a provider wide monthly incident review group was held to discuss this.

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.

It had been determined that moving people’s bedrooms within the service would be beneficial for their wellbeing outcomes. The registered manager told us, “Social stories are going to be made nearer the time, as if it’s too soon it will get them (people) anxious. Mental capacity assessments and best interests decisions will be done. We’ve discussed it with the people involved in the moved and their families. People will be involved in decorating their rooms. We’ve had the same workmen for 15-18 years so they know people well. They’ll come with colour charts and let them choose.” Relatives confirmed they were aware of the decisions, with one relative saying, “I have been told about it. The manager told me and consulted me. It’s fantastic news.” This demonstrated steps were taken to involve people and their relatives in transitions to empower them, but that staff were aware of the need to start these conversations at the right time in the process to lessen any anxieties involved.

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.

Staff were aware of their responsibility to safeguard people from harm and abuse. One staff member told us, “I completed online safeguarding training. I would complain to management. For example, if I witnessed staff shouting at a person, I would tell the manager and team leader.”

Appropriate referrals were made to the local authority to inform them of any safeguarding concerns that had occurred. The registered manager told us, “[The quality manager] keeps a log of all of them. We notify everything to Surrey and Sussex local authority. We also now report all low-level incidents to them both now following Surrey’s process changes. I believe all staff are up to date with safeguarding training. We have in-house training for this as well as external.”

We reviewed the financial logs held by the provider for people. We identified all balances added up and costs were within what was expected for purchases such as activities, shopping and fuel.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Records showed that 1 person was deprived of their liberty with the necessary legal authority. This authorised the use of seclusion at night to manage heightened behaviours of anxiety and aggression caused by other people living at the service. However, it did not include information that when secluded the person was known to harm themselves when distressed. Neither was this reflected in the person’s care plan or risk assessment. This meant steps had not been considered and were not documented to protect the person from possible abuse. Staff told us they provided the person with verbal reassurance through the locked door, but this was not always successful in preventing harm and there was no information about when staff should seek medical advice in the event of an injury.

Improvements however had been made to the monitoring and recording of seclusion at night and updates had been made in response to a safeguarding concern to reflect the use of seclusion during the day. Other less restrictive options such as alternative accommodation within the service were recorded in the deprivation of liberty documentation. Although plans were in place to address this, these had not progressed since our last inspection. Some temporary measures had been taken to lessen the risk in the meantime, including playing a radio overnight by the rooms of people effected. However, this prevention measure was not always effective. For example, 1 staff member told us, “[Person] woke up and went to the toilet and [other person] was also awake and was agitated kicking the wall, banging their head. I woke the sleep-in staff and they verbally reassured [person] and I verbally reassured [another person] due to the noise. They were agitated, we checked for body harm, reported injury to their head. It happened 3-4 times [throughout the night] 10-15 minutes of calm and then starts again so we verbally reassure ‘everything is fine’.”

The provider’s plan to move people to different rooms was in place to help reduce these incidents of harm and therefore these changes needed to be completed without delay so incidents of self-harm could be reduced.

The provider’s policy and procedure for positive behaviour support had been reviewed and contained up to date legislative frameworks such as the mental capacity act and approaches that valued and upheld people’s rights and quality of life with the use of evidenced based tools, for example, the assessment of pain in a person with communication or sensory needs.

We found a person’s positive behaviour plan identified triggers and provided guidance for staff about how to react to warning signs of an emotional reaction. However, it did not document preventative strategies to avoid distress. The absence of this information meant expectations were not clearly documented to ensure all staff were accountable to following agreed and consistent support strategies. However, the impact of this was lessened as staff we spoke with understood the person’s needs and how to support them, such as avoiding another person using the service. Following our assessment, the registered manager provided evidence to demonstrate the person’s positive behaviour support plan now included this information.

Other risks to people were managed effectively. One person’s care plan stated they needed the temperature of the water to be checked by staff prior to the person entering the shower. Records demonstrated this was done by staff each time and we saw a thermometer was available in the person’s bathroom to facilitate 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.

We observed window restrictors were in place to prevent people harming themselves or falling, and that the COSHH cupboard was locked. These are substances that are hazardous to health such as cleaning substances.

Action had been taken where elements of the environment had been identified and been found to be unsafe. For example, a recent fire safety audit identified a chest freezer in an exit passageway could cause a risk during a fire due to blocking an emergency exit. Therefore, staff had moved the chest freezer into another room and away from an exit passageway.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Appropriate numbers of staff were available to people within the service during the day. Each person received 1:1 care to ensure their immediate care needs could be met. However, we could not be assured people were receiving support by the correct numbers of staff when in the community. We also identified concerns around sleep in staff being woken up on a regular basis when they were completing 15 hour day shifts either side of their night shift. which left people at risk of unsafe care. This is covered further in the Well-led section of this report.

Staff were recruited safely. This included the provider carrying out pre-employment checks such as obtaining references and information from the Disclosure and Barring Service (DBS). This confirms if potential candidates are of good nature to work with vulnerable people.

Staff received the training they needed to meet people’s needs. The provider’s employment satisfaction survey from 2025 found that 100% of staff felt they had received adequate training to support people. Relatives also stated they felt staff were well trained, with one relative telling us, “I feel they are trained and I’m aware that they’ve attended some training sessions.”

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.

We observed the environment was clean and tidy. Checklists were completed by staff to demonstrate when deep cleans had been completed in people’s bedrooms and the communal areas.

We were informed by the management team that a staff member had been made an infection prevention and control (IPC) champion. Their role was to complete an additional audit to demonstrate that IPC had been checked around the service and any areas for improvement added to an action plan. This was currently not documented. We therefore suggested the provider initiates documenting this audit to evidence its completion.

Relatives also felt staff followed correct IPC procedures. One relative told us, “They always wear the appropriate gear. They have everything nearby.” Another relative said, “I have no concerns with the cleanliness of the home or [my family member]. I see [person] once a fortnight and he’s always clean, shaven and has showers every morning and evening. His hygiene is top notch.”

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 appropriately stored and administered. People’s medicines were kept in individual storage boxes within a locked cabinet. Each storage box had a photo of the person whose medicines it contained. We observed staff members washing their hands before administering medicines, whilst wearing a red ‘Do Not Disturb’ tabard so other staff were aware of their need for concentration.

Staff had received training in medicines and completed a competency assessment twice a year. Stock checks of medicines were completed by staff weekly, with the deputy manager then completing a further check to ensure counts of medicines were correct. We observed medicine administration records (MARS) were completed in full, apart from one evening when the internet in the area had gone down. The staff and management were able to confirm they were aware of this and that additional checks had been completed to ensure people had received their medicines that evening.

Protocols were in place for as and when medicines (PRN). These included when these should be given to a person and the maximum dose in a 24-hour period. We did identify 1 person who had topical creams as a PRN did not have a body map in place to demonstrate to staff where this should be applied on their body. We informed the registered manager who provided us with evidence this had been rectified by the end of our assessment.

Relatives felt their family members were appropriately supported with their medication. One relative told us, “Staff give them medication, and they know exactly when to give it to them.” Another relative told us how staff had adapted to support a person to take their medicines when they had become visually impaired.