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• 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

We looked at 8 quality statements under this domain: Learning culture; Safe systems, pathways and transitions; Safeguarding; Involving people to manage risks; Safe environments; Safe and effective staffing; Infection prevention and control; and Medicines optimisation. We found the provider had a positive and inclusive learning culture. There were effective audits and checks in place to assess, monitor and review quality and safety within the service. People were supported to move safely into the service. People felt safe living at the service and the care and support provided reflected people’s support plans and was delivered safely with respect and kindness. Staff were trained in safeguarding and managers worked with other health care providers to address any safeguarding issues. We found the internal and external environment, premises and equipment to be safe and maintained. There were enough staff on duty to meet people’s needs. Staff were safely recruited and received an induction. The service had safe systems for appropriate and safe handling of medicines.

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.

Relatives told us they found staff to be open and honest when things went wrong. This included informing relatives of when incidents and accidents occurred, and the actions taken to make improvements. A relative said, “They [registered manager] let me know and are open, one incident happened at night, they let me know, were open, no issues with the registered manager.”

Staff were positive that the communication, systems and processes in place to share learning, and opportunities to improve the service were good. The provider had a positive and inclusive learning culture. A staff member said, “De-brief meetings happen following an incident and following a serious incident, the Positive Behaviour Support (PBS) team and others would get involved, this is supportive and helps us consider anything we could have done differently.” Another staff member said, “We have regular staff meetings, and a daily handover. There is a positive attitude to learning and improving what we do.“

The provider’s vision and values are on display and understood by staff and underpins care and support. People received opportunities to participate in the provider’s co-production learning hub. Staff received training in Equality, Diversity & Inclusion as part of their mandatory induction. The provider had a serious incident reporting system and process in place. The provider had robust continuous audits and checks to assess, monitor and review quality and safety.

Relatives confirmed a pre-assessment was completed with the person and them and others where required. Whilst some people had a transition plan that was based on the person’s needs and wishes, not all people had experienced a transition due to personal circumstances, choice and what was in the person’s best interest. A relative said, “Yes a number of years ago, [name] was in hospital and the manager came to visit them in hospital and saw them and had discussions with us about everything and [name] visited the house before hand, handled very well.”

Staff confirmed that people transferring to the service had a pre-assessment and transition plan if this was required. Information was shared with staff and if additional training was required, this was provided. Staff confirmed improvements had been made about how compatibility of new referrals were now considered. Staff told us how information was shared with others to support continuity in care. Comments included, "Since the 2 people moved on who we were struggling to meet needs in 2022, there is more consideration of compatibility, whilst we have had new people move in, we still have 2 vacancies. There is no pressure to fill beds.” Another staff member said, “An assessment is completed face to face. Its' a person centred approach. Staff are given information. Transition plans vary, based on the individual needs. Grab sheet, copy of MARs any protocols, care plan are shared when a person attends hospital.”

One health care professional we spoke to was positive about the pre-assessment process. Whilst the person chose not to visit the service before transferring, the person had participated in video calls and pictures, information, and a video of the environment was shared. We were told, “Whilst this was a planned move [name] chose not to visit the service, staff visited them in their previous placement and involved myself and relative in the pre-assessment. Staff arranged video calls and used photos and videos to show [name] the service which worked really well.”

The provider had a Moving In and Moving On Policy and procedure that was based on relevant legislation and National Institute for Health and Care Excellence (NICE) guidance. People's transitions in to and out of the service was facilitated by a transition coordinator. Pre-assessments were completed before people transferred to the service; compatibility was considered, and any staff training or resource needs were put in place. Transition plans were developed where required and were dependent on the individual needs of the person. Where visits pre-move were not planned, alternative support was provided such as social stories, photos and video calls of the accommodation. Processes were in place to share information with others such as ambulance services, hospitals, and new care providers.

People told us they felt safe living at the service. One person said, “There's always staff around, makes me feel safe.” Relatives were confident their loved ones were safely cared for, a relative told us, “Generally I'm very happy with the placement. [name] is safe and well cared for. What I like the best is the relationship they have with staff, I believe staff genuinely like being with them, there's such as equal relationship, I just couldn't be happier.” Another relative said, “Yes, I phone each week and get a rundown what [name] has done. In other homes I didn’t get a truthful answer, I do feel the manager is only speaking truthful, telling me things I wouldn’t have been told before.” Relatives confirmed they had been involved in mental capacity act (MCA) assessments, discussions and decisions about how care, support and risks were managed. A relative said, “When staff are doing best interest assessments and these have been categorised into different areas, they do assessments and send me the report on the topic, we look at things and any comments are made, the care plan is sent to us to read and ask questions, we made a few corrections to it.” Another relative said, “When a best interest decision is made, I’m one of the parties involved, my name is on the Court of Protection authorisation. I’m invited to be in a best interest meeting, we’ve got one next week with the clinical psychologist about medication, a teams meeting with me, the manager and the doctor. Yes, I’m invited to attend safeguarding and best interest meetings.”

Staff had received safeguarding, mental capacity act (MCA) and deprivation of liberty safeguards (DoLS) training and had access to up to date policies and procedures. Staff demonstrated an understanding of their role and responsibilities in protecting people from risks and avoidable harm. Staff understood the principles of the MCA and the legal framework of DoLS. A staff member said, “I would report anything that I was not happy about, including any risks, support plans not being followed by staff, incidents between people at the service - anything really.” Another staff member told us, “MCA assessments are decision specific; questions are asked using easy read / pictorial information. Best Interest decisions - others are involved such as family and social workers. Decisions have to be least restrictive.”

Observations of staff engagement with people were good. People appeared relaxed in the company of staff and interactions were positive. Staff clearly knew people well including their routines, preferences and what were important to them. Staff picked up on and responded effectively, when people required assistance and or reassurance. Care and support provided reflected people’s support plans and was delivered with respect and kindness and safety maintained. People were consistently given choices and staff were attentive.

The provider had up to date Safeguarding, Whistle Blowing, MCA, DoLS and positive behaviour support (PBS) policies. These were all available and accessible for all staff. However, the PBS policy did not detail the accredited restrictive physical intervention (RPI) to be used. This was raised with the registered manager to follow up. The safeguarding policy did not reference what the local multi agency procedure was. However, we were assured safeguarding incidents had been shared with the local authority and CQC when required. Incidents were reviewed, and de-brief meetings occurred with staff and the person involved. Overall incidents were well documented with evidence of the registered manager completing a review and follow up actions. However, examples of racial abuse towards staff were identified via records, and we saw no evidence of how staff were supported. This was raised with the registered manager who agreed to follow this up.

Relatives confirmed overall they were involved in discussion and decisions about how risks were managed. A relative said, “I have no legal standing but staff will listen and take on board any suggestions. I'm reassured that improvements have been made and that [name] is happy, I've never had any concerns about their care. “

Staff told us guidance to support them in how to mitigate risk was supportive and detailed. Staff gave good examples of how they supported people when expressing an emotional reaction that could escalate, putting the person and others at risk. Staff consistently told us that whilst they had received training in the use of restrictive physical intervention this was only used as a last resort for the minimal time. A staff member said, “We have got to know people well and are able to pick up on triggers / warnings. We use de-escalation by diversion strategies, change of face, offer an activity, change of environment, a drink, a walk.” Another staff member said, “RPI (restrictive physical intervention) is not used frequently, it's always a very last resort.”

Observations concluded staff knew people’s individual needs, routines and preferences well. We saw how staff were able to anticipate potential risks and how they were able to effectively manage these in a calm manner and approach. One person was observed to be recovering from an epileptic seizure and staff were observed to be present ensuring the person recovered well. This reflected the persons epilepsy support plan. People were supported to access the community and they were supported to do this with the correct numbers of staff to ensure safety. Where people chose to remain for long periods in their bedroom, staff respected people’s wishes but maintained regular checks to ensure people’s safety and well-being.

Risks associated with people’s care and support needs were assessed and guidance for staff was detailed and supportive. A person’s epilepsy support plan and risk assessment was well detailed and known by staff. Personal emergency evacuation plans (PEEPS) were found to be well detailed, up to date, and supported staff to evacuate people during an event impacting on the safety of people. Records confirmed people and their relatives were involved as fully as possible in how risks were managed. There was a positive approach to risk taking. For example, people participated in a variety of community and recreational activities, including experiencing new opportunities. These were well planned, and risk assessed to ensure the safety of the person and others. The use of restrictive physical intervention (RPI) was used as a last resort. Four people had been assessed for the use of RPI. Staff were provided with detailed strategies to use to support people with emotional distress, and guidance for staff about the use of RPI was detailed. De-brief meetings were used to discuss with staff and the person what had occurred and if there were any learning opportunities to mitigate further risks. Positive Behavioural Support Plans (PBS); whilst person centred and supportive to staff, information was not always reflective of current needs. For example, one person’s PBS stated unable to express if unwell. The person’s health support plan stated they were able to express pain. Risks associated with the environment, premises and equipment were assessed and regularly monitored.

People told us they were happy with their bedroom and living environment. One person told us the trampoline in the garden was broken, we followed this up with the registered manager. Relatives confirmed the environment and premises was kept in good order and raised no concerns about safety. A relative said, “The environment is well maintained and safe.”

Staff confirmed checks were completed regularly on health and safety relating to the environment, premises and equipment. This included checks on fire safety and legionella. Staff had completed fire training and fire tests were regularly carried out. Water testing and temperature checks were completed. A staff member said, “There are different daily, weekly and monthly checks completed. Any concerns are recorded and reported.”

We found the internal and external environment, premises and equipment to be safe and maintained. Regular checks on health and safety were completed, this included window restrictors, fire and legionella risks. We observed a team leader completing checks of the first aid box and medicines. The environment had been well maintained, fixtures and fittings were of good quality and fit for purpose.

The provider had a Business Continuity Plan that was available to staff and advised of actions required should the service’s safety be impacted upon. The provider completed daily, weekly and monthly health and safety audits and checks on the environment, premises and equipment. Unannounced spot checks were completed, and this covered checks on health and safety.

People confirmed they had allocated staff who supported them when indoors and when out in the community. A person spoke positively about the staff team and how well staff understood and supported them with their care needs and wellbeing. A person said, “Staff are kind, friendly, no shouting they listen and are polite and respectful.” Relatives were confident their family members received the level of staff support required. A relative told us, “There are sufficient staff at all times.” Relatives were complementary about staff’s experience, skills and competency. A relative said, “They [staff] understand very well and deal well with [name] needs. They understand better than we do [family]. They understand their needs and quirks well.“

Staff confirmed the current staff team was stable, there were no vacancies and how well staff worked together as a team. Staff told us how they picked up shifts due to leave or sickness or how bank staff were used to cover shortfalls. Staff were positive that the improvements of having a consistent, established staff team was supportive to people. Staff confirmed recruitment checks had been completed before they commenced, and how they found the ongoing training and support to be supportive. A staff member said, “I have no concerns at all about staffing, people receive their 1:1 or 2:1 hours. We work well as a team.” Another staff member said, “No concerns, ongoing training is good. We've also had specific training that includes, sepsis, epilepsy, cerebral palsy. We have supervision with the manager, they have an open door policy, are very helpful and supportive.”

Observation of staff deployment confirmed there were sufficient experienced and competent staff available. People received their additional commissioned hours. Staff worked well as a team and had good communication. Staff clearly knew people well, the atmosphere was calm and relaxed and staff were attentive and responsive to people.

We were not initially sufficiently assured how the provider had concluded night time staffing and minimum day time staffing levels. Not all staff were up to date with their RPI refresher training; whilst action had been taken to address this, the staff rota did not correctly reflect which staff needed this refresher training. We followed up on these shortfalls with the registered manager and area manager, who provided assurances, including completing and forwarding a risk assessment, updating the business continuity plan and staff rota, and providing details of action taken to ensure staff people were continuously supported by sufficient, skilled and experienced staff. We were sufficiently assured. The provider had robust staff recruitment checks. Staff received ongoing training and support and opportunities to further develop and progress.

Relatives were positive that the environment was clean and hygienic.

Staff confirmed they had received training in infection prevention and control. They had access to personal protective equipment and described the actions of managing an infection outbreak. A staff member said, “We’ve received training in IPC and the use of PPE. If there was an infection outbreak, we would isolate people if possible, use anti-bacterial spray and increase cleaning.”

We observed the service to be clean and hygienic. Staff were seen to be completing cleaning tasks following best practice guidance. Staff had access to a good selection of cleaning products that were securely stored. Staff also had access to PPE and were seen wearing PPE when required.

The provider had an infection prevention and control (IPC) policy and procedure, and this was available to staff and provided expected guidance. The local authority IPC nurse visited the service in June 2024 and gave an overall rating of 95%. Where there were shortfalls, these were being addressed. Cleaning schedules provided staff with guidance of cleaning tasks required and records were up to date confirming what, who and when cleaning tasks had been completed.

People (or those acting on their behalf) told us there was a person-centred approach to support them to have their ‘when required' medicines (PRN), including for medicines that might control behaviour, when they need them. People acting on behalf of people using the service were involved in assessing risks.

Staff had received medicines training and their competency to handle medicines had been assessed. Staff had dedicated time to manage medicines processes, such as ordering, checking stocks, or contacting the GP or pharmacy for advice or support.

Medicines were given as prescribed and recorded. There were clear records of the administration of medicines, allergies, audits, stock control, risk assessments. When a medicine was not administered, an accurate record was made of why it had not been given; for example, the person was away from the service. There was a process for medicines to be administered covertly, including mental capacity assessments and obtaining pharmaceutical advice from an appropriate healthcare professional. Pharmaceutical advice was not always sought. Staff ensured that there was effective communication with the prescriber and pharmacy about people’s medicines.