People in Action - 136 Manor Court Road

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 inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

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.

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.

When accidents and incidents occurred, staff took appropriate action, including seeking medical attention if required. One staff member told us, “If a person had a fall, I would check if they were injured and if needed call 111 for advice or 999 in an emergency. I would make them as comfortable as possible and then fill in the (accident/incident) form and record it in their notes.”

Effective systems were in place to identify any trends or patterns in accidents and incidents so actions could be taken to mitigate emerging risks. Any lessons learnt were discussed in team meetings.

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’s needs were fully assessed before they moved into the home. This information was used to develop care plans and risk assessments to ensure staff had the information needed to provide safe, personalised care.

Staff knew people well and demonstrated a good understanding of their needs. Staff worked closely with health and social care professionals to ensure people achieved good outcomes. One staff member said, “We all (staff) know people very well and pick up on any changes in their health or mood, so they get the support they need quickly."

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.

People felt safe with staff. One person told us, “Yes”, and gave us a thumbs up with a big smile. During our visit we saw people were relaxed and enjoyed the company of staff. We observed positive interactions with people who were joking and initiating playful banter with the staff.

Staff had received safeguarding training and understood their responsibilities to keep people safe. One staff member told us, “I would speak to the person to gather the facts, ensuring they were now safe and report any concerns to the manager as soon as possible.”

Records showed the management team had referred safeguarding incidents to the Local Authority (LA) and CQC appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service was meeting these principles for example, care records contained capacity assessments and where needed, for people assessed as not having capacity, decisions relating to aspects of their care were made in people’s best interests.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were involved in regular fire evacuation drills, so they were familiar with the sound of the fire alarm and the importance of quickly moving to safety. People also had personal emergency evacuation plans (PEEPs) and staff knew what support each person required in the event of an emergency.

Risk assessments were in place to guide staff on how to support people safely, to mitigate risks associated with for example, falls, choking and people’s mental wellbeing. Records confirmed staff had followed these instructions.

Care records and risk management plans had been regularly reviewed and updated where needed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff had completed fire safety training. Discussions with staff demonstrated they understood their responsibilities and the action they needed to take to keep people safe in a fire or other emergency. Information staff and the emergency services needed to keep people safe in the event of an emergency was up to date and easily accessible.

Processes were in place to ensure the home and equipment were regularly checked and maintained in a good working order. Staff had received health and safety training and understood their responsibilities to maintain a safe environment which was free from trip hazards to reduce the likelihood of potential falls as people moved around their home.

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.

Rotas demonstrated staffing levels were maintained and people were supported by a consistent staff team.

During our visit we observed staff engaging with people in a friendly and caring manner. Staff were available when people needed them and people's requests for assistance were responded to promptly.

Staff had been recruited safely in line with the provider’s safe recruitment processes to ensure their suitability before they started working at the service. New staff received an induction which included training and working alongside more experienced staff to learn about their role and people’s individual needs. One staff member said, “We do lots of training to keep our skills up to date."

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.

The home was clean, and staff had been trained in infection prevention and control.

During our visit we observed staff washing their hands regularly and using personal protective equipment (PPE) appropriately.

The Registered manager regularly completed infection prevention and control audits which highlighted any shortfalls, if any, and the actions needed to address these.

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.

People received their medicines as prescribed. Staff responsible for medicines management had completed training and their competency to administer medicines safely was assessed.

Protocols for medicines prescribed ‘as and when required’ (PRN) included guidance in terms of medicine to be administered, reason for administration, and the maximum dose to be taken in 24 hours.

Clear guidance and body maps were in place to inform staff where to apply prescribed creams on the person’s skin. While none of these creams contained flammable ingredients, information was available to staff, in the event they were prescribed.

Medicines were stored safely, and records viewed demonstrated the temperature of the medicines cabinet and fridge were checked daily.