Three Sisters

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 effective systems and processes in place to ensure incidents and complaints were reported and investigated. Staff recorded and reported all incidents, accidents and complaints. These were investigated and action was taken to help prevent reoccurrence. We reviewed records relating to accidents and incidents and found the registered manager recorded details of debriefs that had been held. Lessons were learnt to continually identify and embed good practice. Learning from events or incidents were communicated to staff on an individual basis and at staff meetings. Care plans and risk assessments were updated when changes were needed. Relatives told us they were informed when things had gone wrong and what had been done to improve the home.

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. Information was obtained from people, and others involved in their care, about their people’s needs and risks to their safety. As a result, people had individualised care and risk management plans which helped to ensure they would receive safe and appropriate care and support. Relatives felt the support their loved ones received was effective. One relative said, “My [relative] tells me they are safe here and would not want to come back after their home visits if they did not feel safe.” Another relative told us, “I have peace of mind knowing [relative] is safe day and night."

The provider had systems and processes in place to help ensure people were protected from abuse and neglect. A safeguarding policy was in place which outlined types of abuse and how to escalate any concerns. Staff knew about safeguarding processes and had received training in this area. Staff were able to tell us the importance of reporting any concerns to the management team and what action they could take if their concerns were not addressed. People looked comfortable and relaxed with the staff who supported them and with each other. People said they felt safe. Relatives did not raise any concerns in relation to people’s safety at the home.

People had up to date risk assessments and behavioural guidelines describing the support they needed to keep safe. Staff understood the importance of having up-to-date risk assessments to help minimise risk for people. Staff understood there were times when people became distressed and took steps to understand why a person was distressed and what support they needed to express their emotions. Staff knew people well and used distraction techniques to divert people to places or activities that helped them feel safe. Staff were able to tell us how they supported people with their day-to-day risks. A staff member told us, “I assess the situation prior to caring for them. For example, one service user likes to go into the kitchen, so I risk assess before they go in. I follow lots of policies and procedures and follow care plans/risk assessments.” Relatives told us staff looked after people well and kept them informed of any changes which included minimising risks to ensure people were safe. One relative said, “The staff are keyed up in managing risks and they always talk to me if they are changing anything.” We also saw staff received appropriate supporting from the behavioural support team which helped staff further develop their knowledge and skills. The registered manager explained behavioural risks were reviewed by the internal behavioural team, and they provided support to manage any changes and challenging behaviours people may present. The registered manager told us they had regular meetings with the behavioural team to discuss people’s risk and how they could be supported further to mitigate these risks.

The premises and environment were adapted to meet people’s individual needs. People’s rooms were personalised. The home was clean and tidy, which ensured people were able to move around safely. People had their own en-suite. Communal areas were very minimal, but this met the needs of the people living at the home. The provider had detected and controlled potential risks in the environment. Checks were completed to ensure the environment was safe for everyone who lived at the home. This included daily weekly and monthly checks.

There was enough staff to support people safely. There were plans in place to utilise staff to when responding to any challenging situations. During our observations, we found no concerns in relation to staffing, everyone had their allocated staff and were busy completing their planned activities. We saw staff were available when people wanted them. Staff rotas confirmed there were enough staff to support people safely. The majority of staff told us there was enough staff on shift. Relatives spoke positively about staff. One relative said, “My [relative] has been here for about 8 years now and [staff] go out of their way to help [relative] feel safe. They know [relative] and they have their own core staff team.” Staff were recruited safely. Records showed relevant pre-employment checks, such as criminal record checks, right to work in the UK, references and proof of the person’s identity had been carried out. Staff had completed key training such as on learning disabilities and first aid to perform their roles effectively. The registered manager told us staff have completed training required for their role. There was also the opportunity to get additional training or support if needed.

The provider had effective systems and processes in place to minimise the risk of infection and ensured there was a clean environment for people to live in. An infection control policy and cleaning schedules were in place, which staff completed. Staff had completed training for infection prevention and control, as well as food safety and health and safety. Personal Protective Equipment (PPE) was readily available at the home. Staff confirmed they had access to PPE when needed. There were handwashing facilities available to all using the home. Systems were in place to prevent and minimise the spread of infection to ensure people’s experience was safe.

The provider had systems and processes in place to ensure the safe management and administration of people’s medicines. People experienced safe support from staff with regard to their medicines. People were given their medicines by staff as prescribed, and this was recorded on their medicines administration record (MAR) by the staff. Person centred guidance was in place to support people to have their ‘when required' medicines (including for medicines that might control behaviour) when they need them. People’s medicines were reviewed using STOMP (stopping over-medication of people with a learning disability, autism or both) principles. People were supported by staff who understood their individual medicines needs, for example, people who experienced seizures had risk assessments and care plans in place. We found some concerns in relation to storage of certain medication; this was raised with the registered manager who took prompt action to address this. Staff had completed medicines training, and their competency was assessed, to make sure they could support people with their medicines safely.