Mary House

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 Requires Improvement. At this assessment the rating has changed to 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 improve, identify and embed good practice. Staff knew the procedures to follow and the importance of making people safe. Processes were in place to manage and record accidents and incidents. The registered manager kept an overview of accidents and incidents and undertook root cause analysis when required. Any issues were discussed at staff handover meetings, team meetings and at supervisions. If patterns or trends were identified, they were discussed as a team to minimise risk and prevent a recurrence. The registered manager said, “All reports are reviewed and signed off, I look at what needs addressing, what needs reporting, and keep families informed. We undertake root cause analysis which includes, clinical and health and safety procedures, individual risk assessments, where and why/how it occurred, and preventative actions.” Relatives told us that they were kept informed when things went wrong and how the service learned from incidents. One relative said, “Totally honest and transparent,” another said, “If anything happens, they inform us immediately.”

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 move into the service was planned, slow and focussed on what best suited the person themselves and their families. The transition was as long as needed and could be up to 6 weeks to allow the person and family to adjust to changes to their lifestyle.

When people moved or were admitted to hospital, staff worked with other managers and professionals to ensure smooth transitions and that all necessary paperwork was up to date. A hospital passport which was a condensed care plan and contained key information about people was used when a person had to go to hospital. These were regularly reviewed and updated. During hospital visits and overnight stays, staff from the service would accompany people and remain with them throughout their visit, including overnight. A senior staff member told us, “If someone needs to go to hospital, we send one of their key workers with them to reduce anxiety and help settle them.” A health professional said, “The team at Mary House make sure the transition to hospital is smooth.”

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 lived safely at the service, supported by a staff team who knew them very well and knew how best to avoid any harm. Staff were also aware and confident and reported when things went wrong. Relatives told us they felt their loved ones were safe and happy at the service. Comments included, “I can totally relax now, because I know they are safe” and “I have so much trust in the home, they are so caring and kind.”

Safeguarding and whistleblowing policies were in place at the service and were regularly reviewed. Managers and staff were confident of the steps they would take if they came across a safeguarding situation and staff also told us they were confident to use the whistleblowing process if needed. Whistleblowing is a legal process where concerns can be reported anonymously by staff. Staff had received training in safeguarding and were able to tell us of situations that would amount to an issue that needed reporting. We observed safe practice when staff were supporting people 1 to 1. Staff attended to their needs in a safe way, safeguarding them against injury and promoting their well-being.

Staff had received training in safeguarding and The Mental Capacity Act 2005 (MCA). The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. The documentation supported that each DoLS application was decision specific for that person. For example, regarding restrictive practices such as seat belts, and CCTV coverage in bedrooms specifically to monitor for seizures at night. We saw that the conditions of the DoLS had been met.

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.

Each person had up to date individual care plans and risk assessments. Staff and families had access to peoples’ risk assessments and care plans. The care plans and risk assessments were all computerised and staff entered daily notes on hand-held devices. These provided information about people’s risks and mitigation strategies for staff to provide safe and effective care. Staff were knowledgeable about the people they supported, and the risks associated with their care. This included managing risks for those who lived with epilepsy, diabetes, PEG care, (Percutaneous Endoscopic Gastrostomy) personal care, nutritional and hydration support, and what to do when people become distressed. The care plans reflected what staff told us.

Risk assessments supported staff to manage identified risks whilst ensuring people's rights and independence was promoted and respected. Positive risk taking was supported and encouraged in line with the principles of Right support, right care, right culture to help people learn new skills, such as hydrotherapy and eye gaze technology (This assistive technology enables people to communicate, play games/music providing a hands-free input method) and to enjoy accessing the community. There were arrangements in place to deal with foreseeable emergencies and to maintain the safety of the premises. People had individual emergency evacuation plans in place which highlighted the level of support they required to evacuate the building safely in the event of an emergency.

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 premises were purpose built and all areas for people, both bedrooms and communal areas were on the ground floor with easy access to safe garden/patio areas to all sides of the building. All bedrooms had access to large bathrooms (Jack and Jill, which means a shared bathroom between two bedrooms, which were also wet rooms with shower and bath facilities. For the shower there was a padded bathing trolly. Protocols were in place for staff to follow if a person should experience a seizure whilst in the bath or in the hydrotherapy pool, also on site.

Communal areas were spacious and corridors wide to accommodate wheelchairs. Peoples’ bedrooms contained well-maintained good quality furniture with technology used to ensure peoples safety. For example, sensor equipment for those who were a risk of seizures whilst in bed. People who were at risk of pressure damage had specialist mattress (pressure relieving mattresses) equipment that automatically adjusted to the persons weight and their functionality was checked daily.

Due to peoples’ complex needs, medical equipment was in constant use. People had their own suction machines, that were maintained as per the manufacturer’s instructions and checked daily, a spare suction machine was located in the main communal area for emergency purposes. The service had a defibrillator in the main reception area, checked and ready for use if required.

Peoples’ personal equipment that maintained posture, and supported independence to move around the home safely were well maintained and an overview kept ensuring checks were undertaken and all equipment was fit and safe for use. This included wheelchairs, overhead hoists, bath and bath aids. Hoists used to safely lift people were checked on a regular basis by an external company.

Personal emergency evacuation plans (PEEPs) were in place. PEEPs were in care plans and a copy kept in a grab bag near to the front of the service for immediate access when needed. All certificates relating to gas, electricity and legionella were in place and in date.

The hydrotherapy pool had checks of water quality undertaken regularly and temperature checks of water daily to ensure it was safe to use.

Safety checks had been carried out on fire safety equipment for example, fire extinguishers, fire blankets and doors. A fire risk assessment was in place, and all actions form the most recent fire safety visit had been completed. Alarm testing was carried out weekly and mock evacuations of the service were carried out.

Relatives were complimentary regarding the safety of environment and the facilities available. One relative said, “It’s a lovely place, clean, spacious but homely and they have ensured its safe, security is good, and my loved one’s wheelchair is clean and works safely. I think it’s safe and well-kept. Even the outside areas are improved”

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.

There were enough suitably trained and experienced staff available during the day shifts to support people safely. This included some people who received with 1 to 1 support and some that required 2 to 1 support when in the community. Rotas evidenced that extra staff were deployed in advance to cover hospital appointments. This had ensured that safe staffing numbers were maintained. We also noted that when staff attended training sessions to update skills, agency staff were booked to ensure staff could attend the training.

The service had been actively recruiting for staff, both nurses and care staff and 2 new nurses and 5 care staff had recently been recruited. As there had been sufficient applicants and interviews booked, recruitment had been paused. Nurses and care staff from an agency were used to fill the gaps. These staff knew the service and people very well.

New staff went through a thorough induction process and were supported with regular supervision meetings and spot and competency checks. Staff were fully trained in all key areas for example, medicines, epilepsy management and moving and handling.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least 2 references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Registered nurses have a unique registration code called a PIN. This tells the provider that they are fit to practice as nurses. Before employment, checks were made to ensure the PIN was current with no restrictions.

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 service was clean throughout with a team of domestic staff working monday to friday to ensure the prevention of infection and maintain a high standard of cleanliness. Staff had all received training in infection prevention and control (IPC) and there was a large supply of personal protective equipment (PPE) which was used appropriately by staff.

IPC and PPE policies were in place and were reviewed each time government guidelines were updated.

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.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved families and appropriate health professionals in planning, including when changes happened. Staff supported people to have their prescribed medicines and followed best practice for administering medicines. Staff documented medicines clearly in care plans and made them available when people moved between healthcare settings.People could not share their views regarding medicines, but families told us, “The staff keep us informed of any changes,” and “I trust them, I know there have been concerns, staff have been very transparent, I know improvements have been made.”

Since the last inspection changes had been made to the management of medicines to ensure robust oversight. The service organisation used an Electronic Medication Administration Record (eMAR). This has reduced the amount of medicine errors. Staff talked openly of how they had improved medicines practices with further training. Medicine givers have all received extra training and support to give medicines safely. The staff worked closely with the GP and the Medicines Optimisation in Care Homes team, (which is a program by NHS England, which focuses on improving medication management).

The clinical room was large and well organised. Oxygen bottles were stored and managed safely. All medical equipment such as blood pressure machines, suction machines, catheter and PEG equipment were safely stored and checked to ensure they were maintained, in date and safe to use. Clinical room temperature and clinical fridge temperatures were checked and recorded daily.

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled and stored safely. We observed staff giving medicines safely and that they were recorded accurately on the eMAR. Risk assessments were in place for certain medicines. There were detailed epilepsy, constipation, diabetic protocols in place, with specific actions for staff to follow. All discrepancies and medicine errors were recorded and investigated and action taken as required. Daily and monthly audits were carried out, and any shortfalls were addressed. Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place however, they lacked individual personalisation and were not robustly linked to a pain care plan or pain tool. On discussion with staff, they were able to discuss how people showed they were in pain or discomfort, but this was not easily found within people’s documentation. This was fully acknowledged by the management team and was being addressed.

The staff were aware of the protocols about Stopping Over Medication of People with a learning disability, autism or both (STOMP). A copy of this was available on the medicine trolley in separate files along with epilepsy, diabetic and PEG protocols and risk assessments.