Harboro

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 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.

Incidents and near misses were reported, reviewed and analysed for themes, and actions were tracked to completion. Staff received feedback from audits and incident reviews during team meetings and supervision, which helped embed safer practice. Duty of candour was understood and applied when things went wrong, and people and relatives were informed of changes made.

Relatives told us they were kept informed when issues occurred and gave examples of collaborative problem-solving, such as agreeing a hospital-avoidance protocol with the GP and learning disability team to reduce avoidable admissions. One relative said, “We put in place a hospital protocol prevention plan… very pleased with the way it has worked.”

Staff described clear processes for recording incidents on the digital care system, escalating to duty managers, and notifying families. Leaders explained how safeguarding concerns were uploaded to the local authority portal and monitored through logs. Staff told us the provider offered debriefing sessions if an incident had impacted on staff.
 

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.

Pre-admission assessments were thorough and included compatibility checks, risk assessments and liaison with external professionals. Staff used familiar faces and visual tools to support understanding during moves, and trial visits or respite stays were available to help people settle.

Relatives told us the provider worked closely with health professionals to manage changes in need and prevent unnecessary hospital admissions. There were positive examples of planning, such as additional night staffing during periods of ill-health and joint work with GPs and specialists to agree proactive care strategies.

Staff explained that admissions and changes were communicated through multiple channels, including the digital care system, team emails and handovers.
 

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 recognised the signs of abuse and discrimination and knew how to escalate issues internally and to external agencies. People were supported to understand their rights and how to raise concerns in ways that worked for them, including advocacy where needed.

Relatives told us they felt their family members were safe and described staff as responsive to non-verbal cues and able to reduce escalating behaviours. One relative said, “Yes, I think [person] is very safe.”

Safeguarding was embedded in the provider’s systems and processes. Pre-admission assessments included safeguarding histories and risk factors, and the provider’s policy reflected current legislation. Staff supervision records showed safeguarding was a standing agenda item, and staff were encouraged to speak up if they had concerns. Staff told us they had completed safeguarding training and could describe escalation routes, including notifying safeguarding leads and submitting concerns to the local authority portal. Leaders maintained a central log of safeguarding alerts and monitored Deprivation of Liberty Safeguards (DoLS) applications to ensure people’s rights were protected.
 

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.

Risk assessments were co-produced and focused on enabling people to do the things that mattered to them. Plans described early signs of distress and agreed strategies to prevent escalation, including positive behaviour support (PBS) approaches and proportionate measures such as weighted blankets. Reviews considered what worked well and what needed to change so people could remain safe and active.

Relatives told us they were involved in care and risk decisions and gave examples of tailored support, such as agreed seating and feeding positions and additional staffing when needed. One family member said, “[They are] funded to have one-to-one care all the time and two-to-one care as required.”

Staff explained how they used dynamic risk assessments and PBS plans to adapt support in real time. Risk management focused on least‑restrictive, enabling approaches so people could pursue ordinary life outcomes, including access to the community with staff support.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived in a homely service that was clean, well maintained and adapted to meet their needs. The environment was personalised, with people’s rooms reflecting their preferences and supporting orientation and comfort. Safety checks were carried out regularly, including fire drills, emergency lighting tests and equipment servicing, and any hazards were identified and addressed. Core safety certification, such as gas and electrical checks, was up to date, and equipment like track hoists and evacuation aids was available and maintained.

Relatives told us the home was generally clean and tidy, with no unpleasant odours. Staff explained that environmental issues were logged, prioritised and resolved. We saw evidence of environmental adaptations that supported safety and independence, such as wide doorways. Outdoor areas were level, well-lit and secure, helping people move around confidently and enjoy safe access to fresh air.
 

Staffing arrangements did not always ensure people consistently received the right support to access the community or maintain safe cover during incidents.

While relatives generally felt staffing was adequate and valued continuity from long-standing staff, some reported occasions where short staffing limited opportunities. One family member said, “Occasionally they are short staffed and [person] is unable to go out.” Another relative told us, “Whenever I visit, I am happy that there are enough staff.”

Staff confirmed they usually had enough time during shifts to support people well, but described situations where behavioural incidents requiring two staff temporarily left one staff member covering the rest of the home. One staff member said, “When one resident’s behaviour escalates… you can be left with just one staff member.”

Recruitment processes were robust overall, with identity, Disclosure and Barring Service DBS and reference checks completed.

Staff received regular supervision and training, including learning disability and autism, with competency checks for medicines administration. Agency staff were not permitted to administer medicines.
 

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 home was clean and hygienically maintained, and cleaning schedules, audits and spot checks were in place to monitor standards. Waste was managed safely, and cleaning products were stored securely in line with Control of Substances Hazardous to Health (COSHH) requirements. Care plans included detailed guidance on personal hygiene, oral care and skincare routines, which helped reduce infection risks.

Relatives told us the home was generally clean and well maintained. Staff confirmed they had access to adequate PPE and described established housekeeping routines supported by daily checklists, weekly walkabouts and ad-hoc spot checks. Records showed that IPC audits and cleaning rotas were comprehensive, covering high-touch points, deep cleaning of shared areas and robust food hygiene checks, which supported a safe environment for people and staff.
 

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 using an electronic administration system (eMAR), and staff were trained, competency-checked and supported by two medication champions. Storage was secure, with individual cupboards, temperature monitoring and clear labelling of opening and expiry dates. Care plans contained detailed guidance for time-critical medicines, PRN protocols and specialist requirements, such as liquid-only diets, patch site rotation and the safe use of injectable pen devices.

Relatives told us medicines were stored securely and administered as prescribed. One family member said, “They record it all on their tablets… when I take him out, they give me all I need.”

Staff explained how they checked stock, escalated short deliveries and liaised with the pharmacy to avoid missed doses. Records showed robust governance, including regular audits, allergy alerts, temperature logs and clear communication in handovers. These measures supported safe, person-centred medicines management and reduced the risk of errors.