1 Fengates Road

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 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 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.

For example, when a staff member had made a medicines error, they were required to undertake further training in medicines administration to help ensure they followed safe procedures in future.

The managers had regular quality assurance monitoring meetings to share good practice, what worked well, and to identify trends and analyse where improvements were needed.

Incidents and accidents, safeguarding concerns and complaints were recorded. These were reviewed, discussed and analysed to determine any underlying causes or trends and to identify any actions required to improve the service.

The registered manager understood their responsibility under the Duty of Candour and were able to demonstrate 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.

People told us the staff were available if they needed support. Relatives stated they were informed when their family members required support or treatment from different agencies.

The staff team and managers told us they worked well with other professionals to ensure continuity of care. Healthcare professionals told us they had a good working relationship with the service and communication was good.

The registered manager told us they assessed people in their own setting prior to them moving into the service. One person who was due to move in soon had been visited for an assessment and was supported to visit the home to meet other people. The registered manager told us, “The process will take at least 3 months, and be done very gradually to get the person used to the service, at their own pace. When they first move in, we allocate one to one support for about 4 hours a day until the person gets used to the home and we can be sure what their needs are.”

Staff told us they received good information about a person before they were admitted to the home, so they could understand and meet their needs and wishes.

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.

People said they felt safe from harm and abuse. One person told us, “I always feel safe. Staff are good, everyone is good.” A relative stated, “Overall, I have no complaints or cause for concern about the care my relative receives.”

Staff were aware of their responsibility to safeguard people and who to contact in the event of any safeguarding concerns. One staff member told us, “If I had a concern, I would report to the manager and Surrey safeguarding team.”

The staff received safeguarding training and regular refresher training to ensure they kept their knowledge up to date. A staff member told us, “I have had both E-learning and face to face training in safeguarding.” Staff were able to describe how they would recognise signs that someone was being abused, and what actions they would take.

The provider was proactive in raising safeguarding concerns with the local authority and CQC. They worked with the relevant professionals to investigate concerns when incidents occurred. For example, where a person using the service had raised concerns about a member of staff, the provider had taken prompt action, had conducted an investigation and taken appropriate action in line with the provider’s disciplinary procedure.

The provider understood their responsibilities under the Mental Capacity Act 2005 in ensuring Deprivation of Liberty safeguards (DoLS) applications were submitted as required. At the time of our inspection, nobody was being deprived of their liberty unlawfully.

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.

People said staff knew their needs and met these safely. People were supported to take positive risks. For example, one person had expressed their wish to increase their independence and had started successfully shopping by themselves. People had financial passports in place. These recorded people’s understanding about their finances and how to support them to manage these.

There were effective processes in place to help ensure risks to people were assessed and mitigated. Risks assessed included, falls, accessing the community, self-medicating, finances and restrictive practice. Risk assessments were highly detailed and analysed all areas of the person’s daily life, what may cause the risk, and how to mitigate this. The risk assessments were reviewed yearly or more often if necessary, for example, if the person’s needs had changed.

Care plans contained detailed information about people’s medical conditions, signs to indicate they were becoming unwell and what actions to take. For example, some people were living with chronic conditions managed by medicines. Care plans provided examples of signs and symptoms to look out for, to help ensure staff would be able to identify a person was becoming unwell.

Incidents and accidents were recorded and contained details such as a description of events leading up to the incident, action and response and a post incident analysis. Each report also highlighted what had been put in place to prevent re-occurrence. Following the incident, an action plan was put in place and care plans and risk assessments were reviewed.

Personal emergency evacuation plans were in place for each person. These contained detailed information about each person and the support they required to safely evacuate the building in the event of a fire or other emergency.

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 were supported in a safe and well-maintained environment that met their needs. People’s bedrooms were highly personalised and decorated to their individual taste. We were invited to visit a person’s bedroom, where they proudly showed us their memorabilia and photographs. They told us, “I have a lovely room. I like spending time in here.”

The building had been adapted to meet the needs of people who lived there. For example, people each had their own shower or bath, and there were handrails installed to help those with mobility issues. The home had several different areas where people could choose to spend their time and people had access to a garden which they helped to maintain.

There were effective systems in place to monitor and regularly check the safety and upkeep of the premises. The management team and staff worked together to help ensure any potential risks were identified and addressed promptly such as faulty equipment or trip hazards.

Safety checks were completed daily and weekly in all areas of the home to ensure safe systems were in place. These included water temperatures, window restrictors, fire safety checks and kitchen equipment.

The provider had an up-to-date emergency plan in place to help ensure people were supported in the event of an emergency or adverse event.

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.

People felt there was enough staff to meet their needs, and said there was always someone around if they needed support. The service rarely required the need for temporary staff. The deputy manager told us, “We avoid using agency staff, and the current staff are very good at covering any shifts that need covering.”

The provider carried out checks on the suitability of staff before they started working at the service. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

Staff told us they were happy working at the home and felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service.

Newly recruited staff received an induction which included a welcome and introduction to the different services and people who lived there, health and safety and training the provider identified as mandatory, such as safeguarding, infection control, moving and positioning, communication and health and safety.

Throughout the induction process, new staff were introduced to training specific to the needs of people using the service, such as diabetes, personality disorder, schizophrenia, learning disability and autism and self-harm and suicide prevention. The provider was in the process of rolling out tier 2 Oliver McGowan training for all staff. This is a specialised training course to assist health and care staff caring and supporting people with a learning disability and autistic people.

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.

People told us they felt safe from the risk of infection because premises and equipment were kept clean and hygienic, and relatives confirmed they did not have any issues with cleanliness of the service.

The home was kept clean, tidy and well maintained. Care staff wore appropriate protective personal equipment (PPE) when supporting people to help protect them from cross infection. There were robust cleaning schedules for day and night and staff followed these. The registered manager told us, “We have PPE on site. Any actual outbreaks we will contact environmental health. Where possible, if people become ill, we encourage them to stay in their room to avoid cross infection.”

Appropriate systems were in place in relation to infection control. The provider’s infection prevention and control policy was up to date. Information about the risk of infection was shared appropriately with people using the service and visitors. The registered manager and senior staff carried out audits to ensure high standards of cleanliness. A member of staff told us, “I help to prevent the spread of infection by wearing PPE and cleaning all areas of the home.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people were prescribed medicines to be administered on a when-required basis. We found the protocols in place for these medicines to be administered were detailed and person-centred.

People had medicines profiles in place. These included how the person communicated and how they wanted to be supported with their medicines. People’s health needs assessments included their health conditions, specific needs and allergy status.

Staff received medicines administration training and had their competencies assessed regularly to ensure they kept up their knowledge and skills. They also received STOMP training. STOMP stands for ‘Stopping Over Medication of People with a learning disability and autistic people’. At the time of our inspection, nobody was receiving their medicines covertly.

Medicines were stored securely and at appropriate temperatures. There was an adequate stock of prescribed medicines. Medicines administration records were completed and signed correctly.

Our observations and records we checked showed that people were having their medicines administered as prescribed. The provider had put in place an incident management tool in the event of medicines errors being identified. This included how to determine what happened, how and why, and any learning from this to help prevent this from happening again.

There was a medicines policy in place. There was a process in place to report and investigate medicines errors and incidents. Managers carried out medicines audits to identify gaps and make improvements.