Majestic Care North West 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.

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.

Staff understood and followed the incident recording process; they telephoned the office and completed forms with relevant information following an accident or incident. The registered manager reviewed these, took necessary actions and informed the correct people. The electronic system supported staff to do this easily and in a timely manner.

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.

Leaders conducted pre-admission assessments and captured relevant information from people and their relatives. On occasion the provider was required to update the information they received from the local authority to make sure it was current and accurate. After the first 6 weeks of delivering a care package a review was undertaken to make sure the care was safe and met people’s needs in the right way.

Staff worked alongside professionals such as physiotherapists and occupational therapists. They used their assessments and support plans to help people complete tasks and maintain their independence.

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.

There was a safeguarding policy and staff completed safeguarding training. Staff knew how to raise concerns and the registered manager worked alongside the local authority to raise and investigate safeguarding issues. The provider monitored referrals and outcomes to make sure recommendations were implemented and monitored.

The registered manager was aware of the legal framework for anyone who may be at risk of being deprived of their liberty, although this was not relevant for anyone the provider supported at the time of the assessment.

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.

The managers undertook assessments about risks to health and wellbeing and did this alongside people and their relatives. Reviews were undertaken every 6 months or if there was a change to people’s needs. Staff could access important information via their handheld devices and information was updated in a timely manner.

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

Leaders conducted environmental risk assessments taking account of issues such as accessibility and pets. Where moving and handling equipment was used in people’s homes, staff checked items were in good working order and servicing by an external company was up to date.

Staff completed training in fire safety and made referrals to the fire service to make sure people had items such as smoke alarms and fire-retardant blankets.

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.

The provider made sure staff were recruited using safe processes and made checks such as references and disclosure and barring service (DBS) checks. Rotas were managed to provide consistent staff teams to people and staff completed training relevant to their role, including learning disability and autism awareness.

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.

Staff had access to hand gels and protective clothing such as aprons and gloves and wore these at appropriate times. All staff wore a uniform, and managers conducted spot checks at people’s homes to make sure staff washed their hands and kept the environment clean if this was a requirement of the care package. The provider had processes in place which staff followed if there was an outbreak of an infection.

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.

There was information about people’s medicines to guide staff and the registered manager agreed to look at ways to include more detail, for example where medicines were time sensitive. Staff signed to say they administered medicines according to people’s prescriptions on the electronic system and managers monitored this daily. Staff took account of expiry dates and made sure medicines were ordered on time.

Some people or their relatives managed their own medicines, and this was documented in care plans accordingly.