Mill Street

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.

This is the first inspection for this service. We have rated this key question 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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Additionally, staff demonstrated openness and transparency when incidents occurred. Lessons were learned and shared through team discussions and updates to care plans. For example, after a choking episode, referrals to the Speech and Language Therapy team [SALT] were made and eating guidance was added for 1 person. Staff spoke positively about a culture where concerns could be raised without fear, supported by a clear whistleblowing policy.

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, including when people moved between different services. People experienced safe transitions and continuity of care. Hospital discharges were managed with clear communication, and staff liaised with social workers and health professionals. For example, when 1 person left a healthcare facility unplanned, safeguarding referrals were made promptly, and protocols were reinforced with staff.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff understood safeguarding responsibilities and acted quickly when risks were identified. Records showed timely referrals to local authorities and notifications to the CQC. People told us they felt safe, and relatives confirmed they had no concerns.

The provider did work with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, however further information was needed in some risk assessments. While some risk assessments were detailed and person-centred, others lacked clarity. For example, 1 person’s risk assessment around cleaning products described them as a risk to the person and discussed how they were required to be locked away, however, further down in same care plan it stated the person knew what the cleaning products were for and were safe to use them. Similarly, another person’s care plan did not fully explore the risks around medicine administration. We fed these examples back to the registered manager, who took action to ensure the information in these person’s care plans was clearer.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was adapted for safety and accessibility. Evacuation equipment and an adapted lift were in place. Communal areas were clean and well maintained, and people had self-contained flats they considered their “safe space.” A person told us, “It’s the best place I’ve lived.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staffing levels met people’s needs. Recruitment checks were thorough, including Disclosure and Barring Service checks [DBS] references, and right-to-work verification. People praised staff competence and continuity. A person said, “You can tell staff are properly vetted – they don’t just take anyone.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed infection control procedures. Communal areas were clean, and Personal Protective Equipment [PPE] was available. Training records showed staff had completed infection control modules, and audits confirmed compliance.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medication Administration Records [MAR] charts were completed, and stock balances tracked. Occasional missed or refused doses were documented and followed up.