Mushavi Private Limited

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 assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Accidents and incidents were recorded and regularly reviewed to ensure any learning could be discussed and shared with staff. This reduced the risk of similar events happening. Themes were looked for when people had accidents. Referrals to healthcare professionals were made as required and equipment was implemented to support safety.

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.

Assessments were carried out prior to people using the service. People, their relatives and partner agencies were involved. This ensured the provider could provide safe and suitable care. Information was provided to agencies people needed to transfer to such as hospital.

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 and their relatives told us people received safe care from Mushavi. For example, a person told us, “I feel very safe and comfortable with them [staff].”

The provider had a safeguarding policy, and staff were trained in safeguarding. Staff understood the signs and symptoms of possible abuse and told us they would speak to the registered manager if they had any concerns about people. Staff members were confident their concerns would be acted upon.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Whilst most risk assessments were comprehensive and up to date, some risk assessments were not in place. This included for people at risk of urine infections and constipation. The registered manager told us they would implement these so all staff would have effective guidance about the signs and symptoms of these conditions and be able to take appropriate action. Other risk assessments were in place such as falls, choking and health conditions.

There was a consistent staff team who knew people well, although some staff would benefit from further knowledge about people’s health conditions. Despite this, people and relatives were positive about the support provided and how risks were managed.For example, a relative told us, “They [staff] handle the hoist carefully and safely, giving us peace of mind.”

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

The provider assessed people’s home environments to make sure they were safe and risks were identified. They worked with people, their relatives and, when appropriate other professionals, to ensure people had the right equipment to meet their needs. Where we noted a lack of formal processes to check equipment was safe to use, the registered manager promptly implemented checklists to ensure safety.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Recruitment processes needed improving. Staff received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

Staff were mostly safely recruited although gaps in employment were not explored. This meant the provider could not be assured all relevant information about staff suitability had been obtained. The registered manager took retrospective action to ensure existing staff were safe to work in care and told us of the action they would take to strengthen recruitment processes going forwards.

There were enough staff to keep people safe and meet their needs. People and relatives told us staff arrived on time for care visits and stayed the correct length of time.

Staff received a range of training to fulfill the requirements of their role. People and their relatives were positive about the skills of staff. For example, a relative told us, “They [staff] seem like a good team and are well trained.” However, we identified gaps in some staff members’ understanding of aspects of their role, which had the potential to impact the safety and consistency of care provided to people.

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.

Procedures were in place to protect people from the risk of infection. Staff had received training in infection control. Personal protective equipment (PPE), such as disposable gloves and aprons were provided to staff to minimise the spread of infection. People and their relatives confirmed staff wore these when appropriate. One person told us, “Staff always use PPE.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider’s role relating to each person’s medicines was clearly defined in their care plans. People received their medicines as prescribed although improvements were needed with medicines records. Not all people who were prescribed 'as required' (PRN) medicines had a PRN protocol in place to guide staff when and how to use these medicines. Guidance about external medicines was not always clear. This put people at risk of not receiving their medicines in the most effective way. The registered manager began work to implement PRN protocols and guidance for external medicines at the time of our inspection.

People told us their medicines were safely managed and were happy with the support they received from staff.

Staff had received training and were assessed as competent to administer medicines.