Arshad Mahmood - 56-58 Carlton 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 assessment we rated this key question Good. At this assessment 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.

Effective procedures were in place for analysing incidents and accidents. Each event of this nature was investigated and reviewed by a manager to look for themes or trends, in line with the provider’s policy.

The complaints folder had a single incident written in for the past year, and the process taken by the provider was well documented, including the investigation, resolution and communication to the complainant.

Communication with staff members was robust, with shift handover meetings taking place every morning and evening. All appropriate information about people’s care, and any changes in risk or needs, was recorded on each person’s electronic file, so staff could readily access this. All staff had appropriate induction training to identify, and report concerns to their manager, with follow up meetings taking place.

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.

The provider worked with people and healthcare partners to establish safe systems of care where safety was effectively managed. People experienced well-coordinated transitions, with staff obtaining relevant information from family members and previous services to ensure continuity. A relative described the smooth process they had experienced at the point their relative had moved into the service. They explained that their relative, “was made to feel at home and that they belong” after moving to the service.

Staff understood referral pathways and used them appropriately. This included referrals to SALT (speech and language therapists) and occupational therapists when people’s needs changed. The provider was able to evidence timely professional involvement for swallowing risks, and changes in mobility needs.

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 their safeguarding responsibilities and followed processes to raise concerns which protected people from the risk of abuse. Staff told us they had received safeguarding training and were confident to escalate issues both to their manager and to the local authority. One staff member said, “Some of the residents don’t speak a lot, so we rely on body language and facial expressions to identify how they’re feeling. The person might be withdrawn if they exhibit fear. Look for signs of depression. We check for marks or bruises to the skin and fill in a body map routinely for any marks.” Another staff member told us, “I would report to my managers or I could go to the local authority.” A relative told us, “Yes [person] feels safe, the staff know them and take really good care of them.”

Where applicable, applications for Deprivation of Liberty Safeguards (DoLS) authorisations had been completed and notifications had been submitted to the CQC about any such authorisations granted. DoLS are important human rights safeguards; they aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’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.

Care plans and risk assessments contained detailed guidance for staff to follow, including how to support people safely whilst eating, providing personal care, taking medication, and mobility tasks. Staff we spoke with understood risks to people and how to support them to remain safe. Staff understood people with complex health conditions. Staff had a good understanding of the people’s care requirements and how they like them to be completed.

Care plans and risk assessments were reviewed in line with the provider’s policy, as were individual goals set out for each person using the service. Reviews included the person, and relative where appropriate, and all changes to care plans were agreed with the people using the service, and family members where appropriate.

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 provider had appropriate safety certificates in place and a detailed history of servicing information.

People lived in a safe environment, and staff completed regular checks of communal areas, and bedrooms. People were involved in the upkeep of the service, cleaning and maintaining the environment, where possible, with the assistance of staff.

Although parts of the home required redecoration, the provider had clear improvement plans, and staff kept areas clean and functional. A relative told us that they had seen evidence of furniture being updated at the service, “quite regularly.” However, it was seen that the flooring posed a trip hazard, in the main room by the front door, as there was a gap in between flooring panels, and the edges had been scuffed. There was a trip hazard by the stairs with a low step. This was highlighted to the manager and they advised they would rectify this. Every person had a personal emergency evacuation plan (PEEP) that reflected their current level of need, and all staff had completed fire safety training.

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.

People were supported by sufficient numbers of consistent staff with the right skills. Rotas showed consistent staffing levels, and staff described good teamwork and support from the manager.

People were supported by staff who had been recruited using safe recruitment processes. This included checking new staff members’ work histories and ensuring staff had a Disclosure and Barring Service check (DBS) in place before they supported people.

Staff had completed appropriate training to care for the people using the service, including learning disabilities and autism training. The provider demonstrated they carried out competency checks on all staff members, on a regular basis.

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.

On inspection we noted the property was clean and tidy, and that completed cleaning schedules were in place. The kitchen was in use when we arrived and was cleaned as it was being used by the member of staff and daily temperature checks had been completed for the refrigerator and freezer, without missing any dates for several months. All staff were wearing appropriate personal protective equipment (PPE) and guidance on handwashing was located in the kitchens and bathroom. Audits showed consistent cleanliness checks, and no gaps in cleaning records. Staff meeting minutes demonstrated expectations around cleanliness were regularly discussed.

Feedback we received in relation to the cleanliness of the service was positive. One relative told us the home was, “always clean and hygienic”. They added, “You can smell it’s been cleaned when you walk in.”

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.

Staff received appropriate training and had their competency evaluated before being allowed to administer medicines to people. Records demonstrated that medicines administration records (MAR) had been completed accurately and in line with best practice guidance. Staff ensured that medicines were stored safely in line with best practice guidance

There was clear guidance in place, in the form of PRN protocols, to ensure staff knew when to offer people ‘when required’ (PRN) medication, and evidence they were being used by staff.

There is a medication auditing system in place and staff had medication competency checks completed at random with no more than 3 months in between checks.