ELY DIOCESAN ASSOCIATION FOR DEAF PEOPLE (Cambridgeshire Deaf Association)

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

Safety risks were not always identified, however, improvements in oversight and risk assessment took place during the assessment timeframe. Staff ensured people were involved in making decisions about how they wanted support to be provided. People, those important to them, and staff knew how to raise concerns. Staff understood their duty to protect people from abuse, and this included raising concerns outside of the service if needed. Staff received training which met the needs of the people they supported and met their own communication needs. Staff received support through supervision and appraisal, and their continuous learning was supported. Managers ensured recruitment checks were undertaken on all staff to ensure only those who were deemed suitable and fit, would be employed to support people at the service.

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 told us they received safe care and support, and staff ensured their needs were met. People were able to contact staff at any time, should they need support. The contact methods met their communication needs and differing communication options were used, including text and video calls. One person told us management acted promptly to their individual requests. We found where people asked for changes to their care and support, this was reviewed and acted upon.

Staff told us they were able to approach the management team, and learning took place individually and in group settings, such as during staff meetings. The registered manager was able to demonstrate how learning took place, and how this was then communicated with staff. For example, specific meetings took place which reviewed the care needs of people, and where any accidents or incidents occurred, they were shared with the team to ensure lessons were learnt.

Staff had completed training to support them to carry out their duties safely. Where additional training or supervision was required, this was identified and arranged. The registered manager reviewed accidents and incidents monthly, this ensured any trends or themes were identified and actions were taken to reduce risks of recurrence. A complaints policy was in place which was accessible to people, their relatives and staff. We saw complaints and concerns were reviewed and responded to in a timely manner.

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 safe with staff. Furthermore, people told us where they made specific care requests, these were listened to and acted upon to ensure they felt safe. For example, 1 person told us, “[Staff] are kind to me.” Another person told us, “I feel safe with staff, I do.” People told us staff entered their homes as agreed and helped them with any safety matters relating to their health and home environment. People told us they felt confident and comfortable to raise any concerns with staff, or the registered manager, if required.

Staff had completed safeguarding training and told us they were confident to raise safeguarding concerns with managers. One staff member told us, “I would report any concerns to the [shift manager], I would make lots of notes and record everything.” Another staff member told us, “If it was a serious concern, then I would [contact] my manager straight away. If I didn’t feel they were taking the right action, then I would [contact the local authority].” Staff were knowledgeable of the differing types of abuse they may encounter, and knew concerns could be reported outside of the service if needed. The registered manager demonstrated how to respond to allegations of abuse, including reporting concerns to the local authority.

Processes were in place to ensure safeguarding concerns were identified and responded to in a timely manner. The registered manager demonstrated their oversight of safeguarding matters, and how the training and knowledge needs of staff were identified and responded to. Staff were supported to explore any learning from safeguarding incidents during staff meetings and individual supervisions.

People were supported by staff who knew them. Staff communicated with people in the correct way, which meant they felt safe and were aware of situations or occurrences which may increase risks. One person told us staff assisted them to protect their skin, when it was required. Another person told us, “The support I am getting from [staff member] is giving me the confidence to have time alone.” And “Staff help [me] by checking there are no risks. If there is anything, they will speak to the manager, and it will get sorted out.”

Staff told us they were able to support people safely. Staff knew people well, and knew what individual risks were present for people, and promoted risk reducing measures. For example, 1 staff member told us, “Care plans [and risk assessments] are produced by staff and management. If something changes then we can adjust the care plan.” Another staff member told us about the risks present for 1 person, and how they are monitored and supported safely, whilst promoting independence. Staff assisted people to access and obtain specific safety devices and equipment to meet their communication needs.

Whilst people told us they felt supported, and staff told us they knew people well, we found there were specific areas where improvements were needed. For example, 1 person was at risk of complications due to a specific allergen and the care plan and risk assessments in place did not adequately identify and risk assess this concern. No harm had come to the person; however, robust risk assessment and protocols were not in place. Furthermore, not all care plans and risk assessments considered specific risks of moving and handling equipment, and the timed safety checks this equipment required. The registered manager responded immediately to our findings and ensured these areas were thoroughly reviewed, implemented and shared with staff.

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

People told us they received their care at the time they expected, and staff were kind and competent. One person told us, “I have [number] members of staff. The team I have now are really good. If I am scared, or my stress is high, the staff know, and they will help me.” People were informed of any staff changes, to what they expected, and knew in advance who would be supporting them. People had specific staff boards available in their homes, which could display staff photos, or staff names. One person told us they had previously spoken to the registered manager to request a change in support staff. They told us, “I spoke with [managers] and asked that I don’t have [staff member] anymore. And I don’t. I am glad they listened.”

The registered manager told us they were fully staffed to meet the needs of the people they supported, however, had experienced staff shortages prior to the assessment. Staff told us staff shortages had placed additional pressures on them to cover vacant shifts as they wanted to ensure the people were supported by staff who knew them. During the assessment process, the registered manager implemented a new staffing allocation at the service, which meant an additional staff member would be on duty each day. This ensured a staff member was available for emergency support and cover if needed. This provision also ensured staff had time to review and complete their training requirements, and ensured dedicated supervision time was available. Processes were in place to ensure enough suitably trained staff were on duty, and effective on-call procedures were available to support staff outside of office hours. An electronic staffing system was in place which allowed senior staff to monitor and manage staffing. This meant the management team could act promptly if staff were running late.

During the assessment timeframe we found staff annual competency assessments had not always been completed in line with the providers policy for medicine administration and manual handling. This was acted upon without delay by the registered manager to ensure staff were working safely. The provider recruited staff safely. Processes ensured the necessary checks were completed prior to staff starting. This included employment reference checks, proof of identity and Disclosure and Barring Service (DBS) checks. These checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The registered manager, and the management team, had developed a staff oversight tool to allow them to monitor the working patterns of staff. This ensured adequate rest breaks took place.

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.

People told us they received safe medicines support from staff. One person told us staff always reviewed their need for ‘when required’ medicines. They said, “[Staff] always make sure I have had my medicine, such as headache tablets, if I need them.” Another person told us staff always explain what their medicine is, and they ensure it is administered in the correct way. People were satisfied with how staff supported them to obtain their medicines when they were required.

Staff told us they had completed training and a supervision period, prior to working independently, to ensure they administered medicines safely. Staff told us they felt confident in the training they had completed and the administration process.

Although staff had completed medicines training, and initial supervision when administering medicines had taken place, annual competency assessments had not been undertaken to ensure their practice remained safe. The registered manager acted upon our findings and competency assessments were reviewed during the assessment timeframe. Appropriate systems were introduced to ensure competency checks would be completed annually, or sooner if required, and were in line with the providers procedures. The registered manager showed us how they monitored medicine administration records, and this was completed on a timed basis. This meant any issues were identified and addressed in a timely manner. A medicines management policy was in place to support staff.