OSJCT Hartsholme House

We looked at 3 quality statements under this domain: Safeguarding; Involving people to manage risks and Safe and effective staffing. We found there were effective systems and processes in place to keep people safe. People said they felt safe. Relatives told us their family members were safe and happy with how staff supported them. Staff were trained in safeguarding and knew how to raise concerns. There was a positive open culture where staff felt they could raise concerns if required. Deprivation of Liberty Safeguards (DoLS) had been applied for where appropriate and least restrictive options had been considered. Mental capacity assessments had been carried out when required, however best interest documents did not always record how the decision was made and what least restrictive options had been considered. Care plans contained information about how to keep people safe. People, and where appropriate their relatives were included in discussions about how they wanted to be kept safe. There were enough adequately trained staff to safely meet people’s needs and extra consideration was made to ensure additional staff were available when required. When walking around the premises, we saw that some of the smaller windows had not been restricted on the first floor. The provider had their own systems and processes in place to assess window risk and had completed a risk assessment. However, the risk assessment was not sufficient as individual window risks had not been assessed or consideration had not been made for the cognition of the people who could access the windows or the placement of furniture that increased the risk. The registered manager and operations manager took immediate action and put window restrictors on the remaining windows as a protective measure.

We looked at 1 quality statement under this domain: Independence, choice and control. Staff promoted people's independence and choice. They supported people to have choice and empowered people to make decisions about their care.

We looked at 2 quality statements under this domain: Person-centred care and Equity in experiences and outcomes. People’s care plans reflected their physical, mental, emotional and social needs. People and their relatives when appropriate, were regularly involved in planning and making shared decisions about their care and treatment. Staff ensured people were able to access healthcare in a way that suited their preferences by listening to their personal preferences and past experiences.

We looked at 1 quality statements under this domain: Governance, management and sustainability. There were clear and effective governance and management systems. Information was used effectively to monitor and improve the quality of care.