Head Office

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.

This is the first assessment for this service. This key question has been rated outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved and the provider was open and transparent when things went wrong.

This service scored 88 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. There was a learning culture in the organisation and lessons learned were identified and there was clear communication with staff about changes and improvements. Learning from incidents and people was used to make improvements to the service. A member of the management team was a behaviour management specialist and was able to analyse data and evidence to remove the need for physical interventions in the service. Reviews of people's care and support plans evidenced that no physical interventions had been used by the provider and incidents had decreased since people received support from the provider.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. The management team were actively involved in multi-disciplinary planning meetings prior to people being offered care and support. Initial assessments were then carried out so appropriate and effective support was in place. The management team supported people’s transition to the service by spending time with people in their existing placements so the move to their service, and being supported by a new staff team, was not a new experience which could have resulted in an ineffective transition. A positive approach to risk and behaviour management resulted in successful placements where people achieved their personal goals and dreams.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately. Restrictive interventions were not used in the service, instead behaviour management analysis identified positive solutions to reduce the incidents. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service always worked well with people to fully understand and manage risks by thinking holistically. Care was provided which fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people's care and support were clearly identified in their support plans. Mitigation plans were in place along with strategies for de-escalating incidents. Analysis of data and information demonstrated the occurrence of behaviour related incidents reduced for people. Personal goals and dreams set by people were achieved with them by supporting them to take positive risks. This included going on holiday abroad, taking driving lessons and using wood-working tools and equipment.

The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. People’s homes and surrounding environment were safe. Staff were able to raise areas for improvement in relation to the care environment and the management team liaised with the landlord to make changes and improvements. The provider understood who to contact if they felt people would benefit from additional aids or equipment which staff knew how to use.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care which met people’s individual needs. Staff were provided with a comprehensive induction training programme which included specific training courses about supporting people with learning disabilities and autistic spectrum disorder. Service specific training about positive behaviour support was provided and staff received on-going support from a member of the management team who was a behaviour management specialist. People were involved in recruiting staff for their own support team. They shared information about themselves as part of the recruitment campaign so staff were matched to the person and their likes and personal preferences. The management team confirmed people they support were involved in the recruitment process, "We get the supported person to meet and interview the candidate in their way and if they are happy to take them on, then they are recruited. This way, it involves the person in their own recruitment of their staff team."

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People’s care plans identified cleaning schedules and processes were in place which ensured people’s homes were clean. Members of staff received appropriate training on infection prevention and control (IPC) and the use of personal protective equipment (PPE). We saw evidence of regular supplies and re-ordering of PPE which was delivered directly to people’s homes.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People received their medications safely and people were not over-medicated. The provider’s medication policy specifically detailed compliance with STOMP principles. Stopping over medication of people with a learning disability and autistic people (STOMP) is a national NHS England work programme to stop the inappropriate prescribing of psychotropic medications, an identified priority in the NHS Long Term Plan.