Reflections Community Support

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. Accident and incidents were reviewed, and learning was identified and shared through team discussions. Targeted training was implemented following a previous incident to reduce the risk of recurrence and support continuous improvement.

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. The registered manager told us, “We have reviews at initial assessment, we get as many people involved and ask the person who they would like to be involved in this.” People and family, we spoke with confirmed this.

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. A relative told us, “Staff are excellent they support [name] and I know she is looked after.”

Staff had completed safeguarding training and were aware of how to report any safeguarding concerns. One staff member told us, "Alert to signs of abuse we have training which makes me confident to act." Another staff member said, "I can identify injuries, neglect, behaviour changes and report immediately."

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.

Staff encouraged and facilitated positive risk‑taking in a structured and person‑centred manner, enabling individuals to remain independent, stay connected to their communities, and make informed choices that reflect their preferences, including around diet and lifestyle. Risk assessments were present and up to date for people we reviewed. In one example, tailored footwear support contributed to a reduction in risk of falls for one person. One staff member told us, "Care plans support safe care while respecting choices."

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 had completed an environmental risk assessment on pre-assessment. These were reviewed when any changes occurred.

The provider overall ensured there were sufficient qualified, skilled and experienced staff to meet people’s needs. Not all staff had received supervision in line with the organisation’s quarterly schedule. This shortfall was discussed with the Registered Manager, who acknowledged the gap and implemented an immediate catch-up plan to bring staff oversight back into compliance.

Training records showed staff had completed the mandatory modules required to equip them with appropriate skills and knowledge. During the assessment, we highlighted a gap relating to 'Understanding and Supporting Continence (including Urinary Catheters and Stoma Care)'. The Registered Manager took prompt action to address this and arranged for relevant staff to complete the training to ensure they were competent in this area of practice.

Recruitment procedures were in place, so people were cared for by suitably qualified staff who had been assessed as safe to work with people.

People and their relatives reported positive experiences regarding staff punctuality and consistency. One person told us, 'Yes, they come on time.' A relative said, 'Yes. They are great. Some staff have been coming for over two years.'

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 provider had a policy in relation to infection control and staff told us they had adequate personal protective equipment (PPE) in place. A staff member told us, “I use PPE whenever I’m providing personal care or preparing food, supplies are well stocked.”

The provider ensured that medicines were managed safely and in a way that met people’s individual needs, capacities and preferences. People were involved in decisions about their medicines, including when changes occurred. Training records showed staff had completed appropriate medication administration training and demonstrated a clear understanding of safe practice.

Staff described the checks they carry out to maintain safety. One staff member told us, “We check the right person, the correct dose, the right time, and we record everything on the system.” Another explained, “We follow the care plan and the MAR charts.”

Medication Administration Records (MAR charts) are documents used to record each medicine administered, including the dose, time, and any reasons for omissions. These provide an essential audit trail and help ensure consistency and accuracy in medicines management. People told us they received their medication on time.