231 Brook Lane

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

Improvements had been made following our previous rated inspection and our rating for this key question had improved to good. There were systems, processes, and practices in place to ensure people were protected from abuse and avoidable harm. Incidents were investigated and lessons learned if care had not gone to plan. Staff undertook safeguarding training and safeguarding policies and procedures were available. Staff had a good understanding of safeguarding and were confident to raise concerns if needed, they told us, they were encouraged by the management team to raise concerns. Risks associated with people’s health conditions and support needs, were assessed, monitored, and mitigated effectively. There were safe recruitment processes in place. There were enough suitably skilled staff available to meet people's needs. Infection prevention and control was not always safely managed, however, the manager was responsive during our assessment and started to address some concerns during the assessment process. People received their medicines as prescribed.

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.

We did not receive any concerns in relation to people's experience of this quality statement.

Staff were able to raise concerns and understood their responsibilities in relation to incident identification and reporting. Learning opportunities were shared with staff following incidents. Staff told us there was a culture of safety within the home. One staff member said, “There has been a huge improvement over the last year. There has been a huge improvement generally all round, there is better communication and documentation.” The manager knew how to manage complaints appropriately and would take learning from them. The manager understood duty of candour and their responsibilities in following this process to ensure when things went wrong, staff apologised and gave people honest information and suitable support. Systems were in place to receive and act on relevant safety alerts.

Incidents were reported and recorded appropriately. They were reviewed to find common trends and themes. The manager had oversight of incidents. De-briefs following incidents were taking place. Lessons learned were shared with the staff team and the principles of duty of candour were being met.

We did not receive any concerns in relation to people's experience of this quality statement.

Staff told us, the last transition of a person into the home had involved the person’s support workers from their previous home. This ensured staff received guidance from someone that knew the person well to ensure the person’s needs could be met and they would be compatible with people already living in the home. Care plans were in place to aid the transition. Although the manager had not supported a person to move into the home during the time they had been working there, they were able to provide comprehensive detail about how the process would happen. This included assurances the person would be at the centre of their transition and the appropriate support would be obtained, and the transition process would be regularly reviewed.

We did not receive any feedback from partners about this evidence category.

There were safe systems and pathways for people who were moving between services. When we reviewed staff training, it evidenced there was service specific training in place which was related to the needs of people living within the home. The provider had a referral, admission and discharge policy in place. These showed when people moved to the service risk assessments would be completed. Needs and training analysis would be reviewed, and the provider would effectively collaborate with other providers, commissioners and external stakeholders.

We were unable to gain people’s views, so we spoke to their relatives who told us, they felt their relatives were safe living in the home. One relative told us, “When my relative visits with me they are happy to go back to the home and that wouldn’t be the case if they didn’t feel safe.”

Staff understood their responsibilities in relation to safeguarding and were confident if they reported concerns these would be taken seriously. One staff member told us, “Management do take safeguarding concerns seriously, they keep saying to us, you need to report and document concerns.” Staff were able to give examples of learning which had happened following safeguarding concerns and how this was shared with the wider staff team. The manager had procedures in place to ensure safeguarding concerns were raised and managed appropriately. Procedures were in place to protect people from bullying, harassment, and avoidable harm and Deprivation of liberty safeguards (DoLS) were in place for people who had restrictions in place to keep them safe.

We observed people looked cared for and were well dressed in weather appropriate clothing. People who had one to one support were being supported in line with their contracted support hours. During our on-site visit, one person was experiencing a decline in their mental health and the provider contacted the community learning disability team to request support for the person and additional guidance for the staff team. We noted this person was administered medicines to help them manage their anxieties. There was a protocol in place for staff to guide them in this. This also formed part of the person’s DoLS.

Appropriate safeguarding processes were in place. The manager had good oversight of safeguarding concerns within the home and the staff team had been provided with safeguarding information and training. Evidence reviewed showed staff were raising safeguarding concerns when they arose, and relatives were being notified of these. Improvements had been made following our previous rated inspection and the provider ensured to all relevant organisations were notified as required about possible abuse. The manager had good oversight of DoLS and applied for these in a timely manner. The manager understood the conditions included in people’s DoLS.

We did not receive any concerns in relation to people's experience of this quality statement. People had risk assessments and care plans in place which helped staff to mitigate the risks to people. Staff were able to confidently tell us how they responded in a positive way to people’s distress or agitation. Examples provided by staff showed people were encouraged to take risks that they had been assessed as safe to do.

The manager told us people were supported to manage risks. They told us, other professionals were involved in supporting the team to manage risks. Risks were shared with the staff team through the communication book, at shift handover and during team meetings and supervision sessions. Staff were trained to use positive behaviour support techniques to support people safely when they became distressed.

We observed people being supported by staff who knew them well and supported them appropriately through periods of distress. Staff were supportive and kind and offered redirection, this led to people’s distress de-escalating quickly. We observed staff members following the guidance in people’s positive behavioural support plans (PBS).

Improvements had been made following our previous rated inspection and effective arrangements were in place to monitor and manage people’s risks. We reviewed people’s files, which included reading people’s care plans and risk assessments. We noted the information within these were detailed and provided a clear picture of who the person was and how to support them safely. We were assured the provider was involving people to manage risks.

Relatives told us their family member lived in a clean and tidy home. One relative told us, “The house is clean, and my relative’s room is always tidy and looking good.”

Staff told us they had received fire training, and they felt confident in what action they needed to take in the event of a fire. Staff told us, there were effective systems in place to ensure the environment was maintained safely and understood their responsibilities in relation to the environmental safety. The manager told us fire evacuation drills happened quarterly and these included night-time evacuations which were scenario based. Appropriate maintenance checks were in place and the manager had good oversight of this.

We observed window restrictors were in place. The stairs within the home were safe and had handrails in place for people to use if needed. The fire exits were free from obstruction. We noted the fire doors were well maintained with no gaps and the fire extinguishers were being regularly tested by the appropriate contractors. We observed the Control of substances hazardous to health (COSHH) cupboard was locked. We observed some areas looked tired and would benefit from redecoration. We spoke to the manager about our concerns, and they reported the concerns to their maintenance team.

We reviewed monthly health and safety audits which were detailed and consistently completed. These included COSHH, first aid, environment, and water. We noted actions were followed through to the next audit. The provider had policies in place relating to Health and Safety and Fire Safety. There were correct processes in place to ensure the environment was safe. We were assured the provider had good oversight over the environment.

We asked relatives if people had enough staff to support them. One relative told us, “My relative is funded very highly on 1:1 and 2:1 when needed.”

Staffing levels were appropriate. Staff received an induction, and the training provided gave them the skills they needed to complete their role effectively. When asked about the training programme, one staff member told us, “There is sufficient training, we complete e-learning and face to face training.” Supervisions were taking place and were meaningful. The provider ensured there were enough staff to keep people safe. The manager described a comprehensive induction process for new staff which included mandatory training which all staff members were required to keep up to date with. The manager also told us about service specific training for staff which included epilepsy and autism training. They told us, how they ensure staff were following best practice guidance. The manager continued their own learning and development.

We observed the mealtime experience for people. We did see some staff positively engaging with people, however, we also saw a couple of areas where staff missed an opportunity to engage on a more meaningful level. The manager was aware of where things could be improved and was already working towards achieving this. We were assured on most occasions people were receiving good support and positive engagement throughout their day.

Improvements had been made following our previous rated inspection and the provider ensured staff were suitably skilled, qualified and experienced to meet people’s needs. We reviewed the provider’s training matrix. Where training was outstanding, the manager was aware of this, had a risk assessment in place to mitigate the risks and had plans to ensure the training would be completed in a timely manner. The provider had robust recruitment processes in place to ensure recruitment was safe. Staff received meaningful supervisions and were inducted safely into the home. Staff were trained to be able to safely carry out their role. People’s staffing needs were assessed, and the rota reflected this, any gaps were covered by additional staff. Improvements had been made following our previous rated inspection and the provider had ensured ensure suitable numbers of trained staff were deployed at all times.

Relatives told us, people lived in a clean and hygienic environment which they were able to move around freely.

We spoke to staff about infection prevention and control (IPC). Staff confirmed the home was clean. One staff member told us, “The home is now cleaner, and they have introduced a Health and Safety champion.” Staff confirmed they used personal protective equipment (PPE), had access to a COSHH cupboard which was kept locked and had attended IPC training. Staff understood their responsibilities in relation to IPC. The manager was able to describe how they assured themselves staff were following IPC procedures and understood their responsibilities in relation to IPC. They were also able to describe how they would manage infectious diseases to prevent spread. The manager understood their responsibilities in relation to IPC.

The environment was mostly clean and malodour free. We observed hand gels, paper towels and bins with liners and lids in all areas. Some condiments in the fridge were not labelled when opened so staff would not know when to discard them. Some packet mixes and cake mix gone past their best before date. We found some gaps in temperature recordings for the fridge, freezer, and food. We observed the cleanliness of the kitchen. There were dirt marks and scuffs on a wall and radiator and a cupboard with vinyl chipping off. The manager took immediate action during our site visit to rectify these concerns and told us they were working on improving the cleaning schedules and would undertake spot checks. Some time was needed for these proposed changes to become embedded in practice.

We reviewed the cleaning schedules the provider had in place. These were being completed consistently. The provider had an Infection prevention and control (IPC ) policy. We reviewed comprehensive environment and IPC audits. The IPC audit completed in September 2024 following our on-site assessment visits had an action which was to review and implement more robust cleaning schedules, to include kitchen checks and fridge / freezer temperature recordings. Staff were completing checks within the Safer food, better business pack. Good practice in relation to IPC was not always embedded during our on-site assessment. The manager took action to make improvements during our site visit and improvements had been made following our previous rated inspection to ensure procedures were in place to maintain cleanliness and to reduce the possibility of the spread of infection in the home. However, more time was needed to ensure the appropriate oversight and systems were embedded so all aspects of IPC such as kitchen checks, robust cleaning schedules and fridge / freezer recordings would be managed safely within the home.

We observed people received their medicines safely in accordance with the provider’s medicine procedures. Staff administering medicines, engaged people in the process, explained what they were doing and sought consent. We spoke to relatives about medicines, one relative told us, “I do know all about the medication. I see from the medication administration record (MAR) chart what my relative is administered and have no concerns.”

Staff and the manager understood their responsibilities in relation to medicines management. Staff were able to describe in detail how they administered people’s medicines. Staff correctly described the procedures to follow if a medicines error occurred. They were able to confidently tell us how to administer as required (PRN) medicines. Staff who administered medicines confirmed they have had medicines competency assessments carried out. The manager was able to tell us how they ensured medicines were managed safely. They told us they maintain oversight of the use of sedative / anti-psychotic medicines. The said, “People are supported to have annual medicines reviews with their general practitioner (GP). As an organisation, we have Stopping the over medication of people with a learning disability (STOMP) forums. People we support are on our campaign to change. We have ambassadors and accessible information. The quality assurance audits check for evidence to support STOMP. One of my actions is to raise awareness of medicines within the service.”

Improvements had been made following our last rated inspection and people’s medicines were managed safely. We reviewed 3 people’s medicine files. We reviewed PRN protocols which correctly detailed the maximum dose a person could have, intervals between doses, and the reason the dose should be administered. We reviewed body maps in place for people who were prescribed creams, which showed staff where the cream should be administered. We noted the manager had undertaken recent spot checks of the MAR sheet to ensure people received their medicines as required. We reviewed medicines audits. The most recent audit had an action plan which included involving people more, adding to PRN protocols, creating a plan around STOMP and to increase compliance by training more staff in the administration of rescue medicines . The manager shared with us a risk assessment which detailed of timescales for staff to complete the training. The provider had a medicines policy. There had been recent medicine errors, we reviewed the appropriate action had been taken following the errors, lessons had been learned and they had been reported to the local authority safeguarding team and CQC. We reviewed staff training and the competency framework. We were assured only staff assessed as competent were administering people’s medicines.