Voyage (DCA) Hampshire

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

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always report safety events to external stakeholders.

Relatives told us they had difficulty in contacting the provider when they had safety related concerns. They also told us the provider was not always responsive and did not always feedback any action taken relating to their concerns.

Lessons were learnt to identify and embed good practice. Staff knew what incidents to report and how to report them. The manager shared learning with staff through staff communication channels and team meetings. We saw evidence of change as a result of incidents which had occurred.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always report safety events to external stakeholders.

Relatives told us they had difficulty in contacting the provider when they had safety related concerns. They also told us the provider was not always responsive and did not always feedback any action taken relating to their concerns.

Lessons were learnt to identify and embed good practice. Staff knew what incidents to report and how to report them. The manager shared learning with staff through staff communication channels and team meetings. We saw evidence of change as a result of incidents which had occurred.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

People told us they felt safe with the support the provider was currently providing, however, they told us this had not always been the case. They told us there had been recent improvements which made them feel safer.

We received mixed feedback from relatives about whether they felt their relative was supported safely. In the majority of the supported living households most relatives did feel their relative was safe. In 1 supported living household the majority of relatives did not feel their relatives were safe. We spoke with the provider about this who shared with us a robust plan detailing the changes they had made to improve people’s experience. We were assured by the actions they had put in place, however, time was needed for these actions to be embedded to improve the experience for everyone.

We reviewed evidence of 1 safeguarding incident which the provider had not reported to the local authority safeguarding team or to CQC. During our inspection, the provider submitted a retrospective notification.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. Where restrictive practices were in place Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise, restrictions placed on people to keep them safe.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. For example, people were assessed for risks of falls, risk of choking and risk to their skin integrity. When risk had been identified staff followed actions to keep people safe such as using specialist equipment to monitor people’s health conditions.

The PBS practitioner told us about a person’s unwise decisions which had a negative impact on their health and well-being. The practitioner detailed what had been put in place to support the person to manage this risk. The new actions in place had led to a significant reduction in unsafe practices.

The service detected and controlled potential risks in the care environment. They made sure equipment, and technology supported the delivery of safe care. Health and safety and fire safety risk assessments were completed and checks made of equipment to ensure this was safe to use. Where there were any concerns with equipment, people were supported to report these to the management team and their landlord or appropriate person for further action.

The service did not always make sure there were enough skilled and experienced staff. People and relatives raised concerns about staffing. They told us at times there was a high use of agency staff meaning people were supported by staff who did not know them well. They told us there were communication issues between some staff and people and some staff were not skilled in being able to cook foods people requested. We spoke with the provider about this and received a comprehensive response detailing the additional training and support they had provided to staff and the recruitment and retention improvements they had started making prior to our inspection. We were assured by the actions they had put in place to mitigate the risk to people, however, time was needed for these actions to be embedded to improve the experience for everyone.

Staff received effective support, supervision, and development. Staff told us, managers were supportive, and they had regular supervisions and a comprehensive induction. We spoke with 2 managers who had joined the organisation as support workers and had been supported to work their way up to management level. This meant the provider was fostering a culture where staff had the opportunity to develop in their career.

The manager had a training matrix in place which evidenced most staff had completed all of their statutory and mandatory training to ensure they were able to meet people's needs. Where staff had not completed training, they had been booked on courses to complete this. The provider followed safe recruitment practices.

The service 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 had an up to date Infection Prevention and Control (IPC) policy. Staff attended IPC training. We reviewed cleaning schedules which were consistently completed, and people were supported to keep their environment clean. The areas and households we observed during our inspection were clean.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff received medication training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines.

Some relatives shared with us their concerns over previous medicines errors. We spoke with the provider about this who told us what improvements they had made which had been successful in reducing medicines errors.

Staff told us they felt well trained and confident to support people to receive their medicines safely. Staff supported and involved people to manage their medicines and followed best practice guidance for administering medicines. The staff team were proactive at reporting any changes to people’s medicines promptly.

The registered manager told us, during people’s annual health reviews, Stopping Over Medication of People with a learning disability and/or autism (STOMP) plans were reviewed.