Dove Valley Mews

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 69 (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. Accidents and incidents were appropriately recorded and reviewed. The management team monitored incidents via an online system and high-risk incidents were shared with senior leaders. Incidents were discussed with external professionals, and action was taken to reduce people’s incidents of distress. For example, 1 person was identified as having an increase in incidents. This was being addressed through the use of reward charts, monitoring of potential triggers, staff response, formulating new plans of care and working closely with positive behaviour support (PBS) teams and psychiatrists. Another person was receiving close monitoring and the service held bi weekly meetings with professionals and the persons family, to review their incidents, health needs and care package. Following high risk incidents, staff were involved in debriefing sessions, to discuss what worked well and what could be done differently. People were also offered debriefing sessions, to enable them to explore why incidents occurred and have more positive outcomes in the future. Some staff told us debriefs were not always undertaken following every incident. One staff member said, “We have just had a meeting regarding an incident which happened.” Whilst another staff member said, “I haven’t done any debriefs, I don’t feel like the managers always care, they don’t always check on staff following incidents.” Prior to our assessment it was found 2 incidents had not appropriately been addressed by the management team. This is covered in the safeguarding section of this report. The provider had systems in place to share lesson learned across their sites, when incidents had occurred.

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. We received positive feedback from partners who worked with the service. One professional told us, “[Name] struggles with change but when they moved into Dove Valley Mews the staff worked well with them to help them to settle in. This was very effective.” Records evidenced people had positive outcomes. For example, a professional had complimented the service on working with 1 person to support them to attend health appointments. People received input from a range of external professional to meet their health, mental health and emotional needs. Such as counsellors, psychiatrists, GP's and specialist nurses. One person told us they were settled at the service after having several failed placements previously. Another person had positive a outcome relating to their diabetes, the service had supported this person to eat more healthily and become more active, as well as working closely with diabetic nurses, which had stabilised their blood glucose levels.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. The service had clear safeguarding systems in place and staff told us they felt comfortable to whistle blow on poor practice. One staff member said, “I have never seen anything concerning, but I would report things if needed.” Staff were trained in relation to safeguarding and staff and people told us people were safe living at the service. One person said, “I feel safe here.” A relative said, “We are very pleased with the service, we have no concerns, [Name] is well cared for.” However, prior to our assessment the management team had failed to appropriately respond to 2 safeguarding concerns. This was addressed by the provider and an action plan was put in place. Appropriate action was taken to address these concerns, including thorough investigations, staff disciplinaries, further training and working closely with the local authority. A relative told us these incidents were initially not handled appropriately, but they were now taken seriously, and they were heavily involved in their loved one’s care. At the time of our assessment we found incidents were appropriately monitored and notifiable incidents were reported to CQC and the local authority, as required.

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. Risks posed to people were effectively managed. This included risks posed to people from health needs, such as epilepsy. We found people had appropriate equipment in place and staff monitoring, to ensure risks were mitigated and people had their needs met. People had up to date risk assessments in place and associated care plans to guide staff about how to safely care for people. The service supported people who exhibited behaviours of distress, training was in place for staff about how to effectively support people and keep themselves and others safe. People had detailed PBS plans in place, staff knew people well, including people’s non-verbal cues and de-escalation strategies. A staff member said, “I have had training to deal with incidents and keep everyone safe. The team work well together during incidents. We respect people and understand behaviours are for a reason.” The service also had an in-house PBS trainer. People had bespoke plans in place, to enable staff to support them safely. For example, 1 person had their own outside sheltered area which was effective in providing a calm and safe space for them when they were feeling overwhelmed. Another person was supported by the use of bean bags during staff interventions, to ensure their health needs were protected during behavioural incidents. A staff member said, “We tailor our interventions for different people. We are really good at that here.”

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 purpose-built, bespoke environment, which met their sensory needs and kept them safe. For example, 1 person required a minimalist room, which had built in safety equipment, and this was decorated in their favorite colour to aid calming. This person also liked cooler temperatures, and an air conditioning unit was in place, to keep the temperature at their preferred level. There were safe garden areas for people to access and people received support in their own lounges which were individualised to keep them safe, as well as meeting their preferences. All appropriate maintenance checks were in place to ensure the environment was safe for use. People had access to pictorial fire evacuation strategies and had individualised evacuation plans in place. It had been identified there was a risk posed to staff from supporting a person in a lounge area and a specialised door was put in place to maintain safety. One person had a specialised door to ensure staff could safely monitor their epilepsy, whilst still providing privacy and dignity for this person. A relative said, “It is a very safe environment for [name]. The staff are amazing, they support [name] to remain safe and well cared for.”

Whilst we observed enough staff and staff told us there was enough staff on duty each day to support people, some staff told us the use of agency staff often caused concerns. Staff told us agency staff did not know people well enough and lacked the bespoke training to support some people. A staff member said, “We need some more staff, we use agency and have safe numbers every day. Agency staff are not always good and need guidance. The regular staff have a better relationship with people as they know them. “The provider had recognised this concern and was actively recruiting into the permanent staff team, to attempt to reduce their need for agency staffing. Night staff also told us they felt communication could be better. Staff were recruited safely, were trained to support people's varying needs and received an induction upon commencement of employment. Staff received regular supervisions and appraisals and told us they enjoyed their roles. Staff told us the team worked well together, and we saw staff responding to incidents in a timely way.

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 service was clean and we saw staff wearing Personal Protective Equipment (PPE) appropriately. People were supported to remain independent and staff supported them to do their own laundry and clean their living spaces. People had their own bathrooms and there were several laundry facilities.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Where errors had occurred, appropriate action was taken to ensure people were safe, such as contacting Doctors and implementing 72 hour monitoring. At the time of our assessment, a management medicines audit was overdue, this was brought to the attention of the acting manager on the day and rectified. Senior staff completed weekly stock checks of medicines and daily counts were also in place, to ensure people had received their medicines as prescribed. Detailed protocols for ‘as required’ medicines were in place, to guide staff about how and when people should receive these. Medication administration records (MAR’s) were accurately completed, and staff were trained in medicines administration. Staff had undergone competency assessments prior to administering medicines to people and had also had their competency assessed to deliver epileptic rescue medications. Staff worked under the principles of ‘Stopping over medication of people with a learning disability and autistic people’ (STOMP), which aims to reduce over prescribing of unnecessary medicines. A relative said, “They manage [Name] distress very well, in a person-centred way. They know [Name’s] triggers and know how to de-escalate any heightened behaviour. They only use medication as a last resort.” People had annual or as required medicines reviews. A professional told us, “[Name] has started to refuse their medication. Staff have been creative in finding ways to ensure that they take their medication to reduce the number of seizures they have. This has been effective. Staff have acted on the advice of the Intensive Support Team to facilitate this.” Risk assessments were in place to mitigate risks posed to people from using emollients.