Red Gables

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 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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Processes were in place to ensure risks associated with closed cultures were identified and mitigated, and lessons were learnt to continually identify and embed good practice. There was an open and honest culture within the team, with channels to ensure clear communication. Accidents, incidents, or safeguarding concerns were reviewed, with learning shared at team meetings. One member of staff told us, “Incidents are discussed and reviewed in team meetings including looking at what could be done better.”

The service 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. For a person that had recently moved to the service, a clear transition plan was completed. This included the person visiting the home. People also had hospital passports in place which ensured relevant information was passed over if people were admitted to hospital.

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. There were improvements since the last inspection and the service now shared and acted on concerns quickly and appropriately, including reporting to the local authority safeguarding team and the Care Quality Commission. There was a commitment to minimising the use of restrictive interventions. Since the last inspection least restrictive options had been explored and instead of the kitchen being fully locked, and has included adapting the building to ensure people now had access to part of their kitchen. Appropriate applications were completed to authorise a person being deprived of their liberty.

The service did not always work well with people to manage risks. Although people had risk assessments in place, with areas covered included specific health conditions, choking, mobility, personal care and Emergency Evacuation Plans (PEEPS). Some additional information and control measures were missing from some documentation. We did not find these shortfalls had impacted on people's care as staff knew people well, and the concerns identified were rectified during the assessment. The service supported positive risk taking and provided examples of this. One staff member told us, “People do the activities they want to do, if there is a risk and they want to do it we wouldn't disregard it, we would look at how to minimise the risk.”

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There had been improvements since the last inspection. There was a system in place to carry out environmental checks which was now well maintained. People had been consulted about the environment to ensure adaptations and reasonable adjustments were made. People personalised their rooms and were included in decisions relating to the interior decoration and design of their home.

The service did not always make sure there were enough qualified, skilled and experienced staff. One person was being supported with a clinical task that had been delegated by a health professional. Although staff had received training, competency assessments had not been completed by a health professional. The management team addressed this immediately and arranged for competency assessments to be completed. Staff were recruited safely and received effective support, supervision and development. They received appropriate training including how to support people with a learning disability and autistic people.

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. Staff had access to the personal protective equipment (PPE) they required and were observed to be wearing this throughout our visits. Although the home was observed to be clean, cleaning schedules in place contained some gaps. This had been identified through the providers quality assurance system, and the manager was in the processing of addressing this at the time of the assessment.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People’s medication was reviewed to ensure people's behaviour was not controlled by excessive and inappropriate use of medicines. The service understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both). Medicines were stored securely and there were PRN (when required) protocols in place.