Combe Lea Community Resource Centre

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

The provider promoted a proactive and positive safety culture based on openness and honesty. Staff listened to concerns, reported and investigated incidents, and learnt from them to improve practice. The registered manager had effective systems in place for managing incidents and staff were aware of incident reporting procedures.

The registered manager told us reflective practice was now used following incidents and procedures had been updated to enhance safety. For example, staff wore “do not disturb” aprons when administering medicines to reduce interruptions.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

Records showed information about people was available and shared with health care services when needed. For example, there were hospital passports which included key information about people’s needs to share with other health care services in the event of a hospital admission. There were systems to assess people’s needs prior to admission into the service. Referrals were made to health professionals to request health care support in the event of changes in people’s needs. This meant people’s health care needs were regularly reviewed and met.

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.

The provider had improved how they were managing and recording safeguarding incidents.

There was now a system for recording and investigating safeguarding incidents. Staff had received safeguarding training and were able to explain the steps they would take if they identified any safeguarding issues. This meant that safeguarding concerns were identified promptly, reported accurately, and addressed in line with policy, ensuring a safer environment and compliance with statutory requirements.

People receiving care and treatment can only be deprived of their freedom if the appropriate legal authority is applied for. In care homes, this process is called the Deprivation of Liberty Safeguards (DoLS). DoLS is part of the mental capacity act 2005. We looked at whether the service had followed the MCA guidelines and how the provider handled DoLS.We found that DoLS notifications had been submitted appropriatelyand the manager used a DoLS matrix to help them keep on track of DoLS applications. Staff had received training relevant to DoLS.

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.

Risks to people’s health and safety were effectively, assessed, monitored and mitigated. For example,plans to prevent falls explained the steps taken to minimise these risks, and support for mobility included the details of how people were helped to mobilise. Relatives confirmed they had been involved in developing the care plan and any reviews. Risks were identified and reviewed regularly with people and appropriate measures were put in place to reduce the risk of harm. For example, a motion sensor was installed in one person’s room to alert staff when they began moving, helping to reduce the risk of falls. One relative said, “[Relative’s name] is definitely safe… [relative’s name] has had a couple of falls since being there, in the toilet and by the bed … [relative’s name] now has a pressure mat in [their] room.”

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 appropriate safety checks were made, including legionella checks and moving and handling equipment checks.

The risks related to fire were now managed safely. Staff were trained and were aware of the actions they needed to take in the event of a fire alarm sounding. Effective fire equipment checks took place regularly. Each person had a Personal Emergency Evacuation Plan (PEEP) which meant they could leave the building safely in an emergency.

Daily health and safety walkabouts were completed by senior staff to identify and report any health and safety issues.

The environment appeared safe and well maintained. However, during the inspection we identified that some wardrobes had not been secured to the wall, which could have posed a risk to people. The registered manager took immediate action to address this during the inspection.

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 that met people’s individual needs. Staff had received training to enable them to support people safely.

The registered manager had a system to assess safe staffing levels. Leaders confirmed this was reviewed regularly to ensure safe staffing levels in the service.

Staff received regular supervisions in line with the provider’s policy. Observations of staff care practice were recorded. For example, staff treating people with dignity and respect and infection control.

People told us there were enough staff and that staff were trained. One relative said, “I absolutely think that they have enough staff … they are always attentive…”

And another relative said, “there are plenty of staff, it could be like one for every two residents.”

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 free from malodour. Staff completed training relevant to Infection Prevention Control (IPC).

Managers were undertaking regular IPC audits including weekly IPC spot checks and cleaning schedules were in place.

One relative said, “the home is spotless, they use PPE.”

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 safely and in a person, centred way. The provider had a governance structure and medicines management policy. The provider ensured regular effective medicines audits. For example, the provider had identified some shortfalls in documentation and had already taken steps to address these. Records demonstrated all staff had completed a structured training programme which included online and face-to- face sessions. Staff medicine competency checks were carried out and recorded.

Protocols for medicines taken ‘as needed’ (PRN) were in place. One omission relating to a non-critical topical medication was identified by the inspector during the inspection and corrected immediately by the provider.

Risks had been assessed for medications where there was a risk, for example a fire risk assessment was in place for creams containing paraffin.

Where medicines needed to be given covertly, required documentation, such as mental capacity assessments and best interest decisions was completed.

Medicines were seen to be stored safely.