203 Hoylake 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

We reviewed 5 quality statements under this key question; learning culture, safeguarding, involving people to manage risk, safe environments and safe and effective staffing. During the onsite assessment people told us they felt safe with the support they received. People’s accommodation was safe and well maintained. Staff had been recruited safely. There were sufficient staff on duty to effectively support people. People were supported by staff who knew their needs and preferences. Systems were in place to record and report events which occurred with evidence of reflective practice by the staff and management team.

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.

People and their relatives told us staff were approachable and they felt comfortable raising concerns. One person told us, “I feel comfortable to tell them if I wasn’t happy."

Staff we spoke with were able to describe the process for reporting and recording accidents and incidents. Staff confirmed how the manager and care staff reviewed all incidents to ensure reflective practice and lessons learnt. They also described how learning was embedded to prevent future incidents.

Recent communications received by CQC from the local authority demonstrated the provider undertook investigations following any concerns raised about the service. This evidenced an open culture with opportunities to learn and prevent re-occurrence. We saw evidence of reflective practice to minimise future reoccurence.

Systems were in place to record and report events which occurred. Significant incidents were reported internally with evidence of reflective practice and analysis by the staff and management team.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt protected from the risk of abuse. A person living at the home said, "I feel safe. I would feel able to speak with staff, I have family at home who I can speak with. "

Staff told us they had access to safeguarding policies and procedures. Staff where able to describe the process for reporting concerns and what action they would take in the absence of the registered manager. Staff told us they had completed online training on Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff were able to describe the principles of the MCA code of practice.

Observations showed People were supported to understand safeguarding, what being safe meant for them and how to raise concerns. We saw positive interactions between staff and people.

The provider had processes for reporting safeguarding and a whistle blowing policy was in place. Staff knew how to identify and report safeguarding issues and were aware of whistle-blowing processes. The provider had not always followed their own safeguarding procedure. We identified one event affecting a person’s well-being had not been reported to CQC in line with regulatory requirements. We raised this with the registered manager who retrospectively submitted the notification. Actions were taken by the registered manager following any feedback received in relation to staff conduct or safeguarding concerns. Records confirmed this.

People told us they had the equipment they needed to maintain their safety and mitigate any risks. People told us staff treated them with kindness. People also told us that raising issues about their support with the management team had not impacted on the support they received

Staff advised support plans and risk assessments were accessible. Staff described the policies and procedures in place for managing risk and health and safety when accessing the community.

On observation staff were familiar with the communication needs for people and supported them in minimising risk from harm through documentation, values and good practice.

The provider had policies and procedures in place to guide staff on managing risks when supporting people. However, risks to individuals were not always explicit in care plans with key information regarding specific intervention for one person had not been included. This related to one person who was observed to need specific interventions by staff, but these were not included in care plans. We raised this with the management team who told us they would take action to review.

People told us they were happy with their accommodation.

Staff confirmed they had no concerns about the environment or safety of people living at the home and confirmed they received face to face training to use mobility equipment safely.

We observed people’s accommodation was safe and well maintained. Equipment and décor were in good working order, homely and bright. We observed the staff team reinforcing fire arrangements to a person they were supporting with meal preparation.

There was a refurbishment plan in place and staff confirmed the landlord for the property was responsive to dealing with repairs in a timely way. Processes in place included routine fire checks were carried out with clear evacuation procedures in place. Staff described the equipment used to support people and how they monitored equipment for any changes or faults. There was a system in place for reporting any faults to the senior staff members for action. Staff confirmed that maintenance issues were quickly resolved once reported.

People told us there were enough staff and staff were consistent to ensure continuity of care.

Staff told us there were enough staff to effectively support people and most staff worked full time on a shift pattern basis. Staff described the induction and training programme they received which included face to face and online training courses. Staff told us they had received all the training they needed to effectively support people and to promote choices made by people in their everyday lives.

We observed sufficient staff on duty to effectively support people. People were supported by staff who knew their needs and preferences.

There was a process in place to recruit staff safely. Rotas were developed around peoples assessed needs. Staff received an induction and were supervised on a regular basis to observe practice and check competency to perform their role. Staff receive training they need to meet peoples care needs. This included regular training to support people through periods of anxiety or distress.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.