Arshad Mahmood - 112-114 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 and the complaints folder had no complaints entered for the past year. The manager was able to talk me through the complaints process and how they would achieve a satisfactory resolution when handling a complaint.

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 process as being “as stress free as possible” and “fitting right in” with other residents.

Staff understood referral pathways and used them appropriately. This included referrals to SALT (speech and language therapists), occupational therapists and district nurses when people’s needs changed. The provider was able to evidence timely professional involvement for swallowing risks, and changes in mobility or medical 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. Staff members told us the residents were mostly non-verbal, and staff look for facial expressions and body movements to look for changes in mood. A staff member told us “I would use a body map chart if I found bruising and let the manager know. We complete body maps every month too, when we complete the resident health checks.” Another member of staff told us, “We look for changes in mood and body language to see if something might be wrong.”

A relative told us “[Person] is always happy now. Every time I see [person] they have a smile on their face and are laughing. The staff treat [person] very well and really take 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 people 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 the home required some modernisation, the provider had clear improvement plans, and staff kept areas clean and functional. Staff told us they had seen redecoration and modernisation take place in specific rooms each month and people were involved in this process by having input on paint colour, or furniture chosen.

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 completed cleaning schedules were in place. The kitchen was clean and tidy, and the daily temperature checks had been completed for the refrigerator and freezer. All staff were wearing appropriate personal protective equipment (PPE) and guidance on handwashing was located in the kitchen and bathroom. Audits showed consistent cleanliness checks, and no gaps in cleaning records. Staff meeting minutes demonstrated expectations around cleanliness were regularly discussed. The downstairs bathroom was dated and in need of upgrading, and one of the bedrooms had wallpaper coming away from the wall and a broken plug socket behind the door. However, when making the manager aware of the findings they showed a monthly ‘rolling rota’ of maintenance and decoration for the year, and both bathroom and bedroom were 2 of the next 3 months of maintenance and decoration. The manager also showed us the maintenance log, which had the broken plug socket recorded for earlier that morning as being damaged while vacuuming, and a replacement had been arranged to be fitted later that afternoon.

Feedback we received in relation to the cleanliness of the service was positive. One relative told us the home was always clean when they visited.

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 medicines administration records (MAR) had been completed accurately and in line with best practice guidance. Staff ensured 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 was a medication auditing system in place and staff had medication competency checks completed at random with no more than 3 months in between checks.