Mainwaring Terrace

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 recorded incidents, accidents, complaints and safeguarding concerns, and managers reviewed these to identify learning and improve practice. We saw an example where the provider acted after a fall by reviewing risks and moving a person to a downstairs room to reduce the risk of recurrence. Policies supported an open approach, including duty of candour, and staff explained how managers shared learning through handovers, team meetings and individual feedback.

The provider introduced an electronic system to report incidents, safeguarding and complaints. When IT issues affected the transition, managers continued investigations and added paper records to the system, so the service maintained oversight and did not miss learning opportunities. The provider also reviewed themes and trends centrally and shared relevant learning across services, which helped staff apply improvements consistently.

People and relatives told us managers listened and responded when they raised concerns, and one relative described improved responsiveness. Staff said managers kept them informed about outcomes and actions from reviews.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with health professionals to keep people safe and to make sure care continued when needs changed. Staff kept hospital passports in each person’s file and used these to support consistent care and clear handovers. Staff also described regular input from health professionals, including weekly calls with a GP and liaison with pharmacy and therapists, to help manage changes safely and reduce avoidable harm.

The provider completed compatibility assessments before people moved in; to check they could meet the person’s needs and keep them safe. Although there had been no recent hospital admissions, staff explained how they would support a safe transition if someone needed to go to hospital or return home. This included sharing key information so people would receive care that reflected their needs, routines and communication preferences.
 

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 families told us they felt safe living at the service. Staff understood safeguarding and could explain how to recognise abuse or neglect and how to report concerns. Staff recorded safeguarding concerns, incidents, accidents and complaints on the provider’s electronic system. Managers responded promptly and notified the local authority when needed. Records showed the provider took protective action after incidents and updated risk assessments, with input from health professionals such as GPs where appropriate. The provider also followed duty of candour and spoke openly with families when concerns were raised.

The provider protected people’s rights under the Mental Capacity Act. Records showed decision-specific mental capacity assessments and best interests decisions where people could not consent. Deprivation of Liberty Safeguards (DoLS) authorisations were in place, routinely checked and in date. We observed staff knocking before entering rooms, and people were not subject to unnecessary restrictions. Safeguarding and sexual safety policies were accessible to both staff and people, and staff described how they maintained people’s dignity, privacy and safety in day-to-day practice.

Safeguarding arrangements were well established and helped protect people from avoidable harm and improper treatment. People and relatives said the home acted when they raised concerns.
 

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.

People and relatives told us staff supported them in ways that maintained independence, dignity and preferences. Staff involved people in day-to-day decisions about routines, activities and personal care, and they explained risks in ways people could understand. We saw examples where the provider made changes in response to people’s wishes, such as installing a bath and redecorating a room, while also considering how these changes would be managed safely.

Staff kept risk assessments under review and used them to set out proportionate, person-centred measures to help people stay safe at home and in the community. Staff described how they tailored support to people’s sensory needs, communication styles and behavioural cues so people could take part in decisions and understand choices and risks. This helped staff provide consistent support and reduced the risk of avoidable harm.

People were supported to take part in everyday tasks safely. Staff gave examples, such as supporting someone to walk to local shops, take part in outdoor activities and build daily living skills. Families said staff listened and acted when they raised suggestions. Staff also described how they worked with external professionals, such as Positive Behaviour Support practitioners, GPs and therapists, to adapt plans when people’s needs changed.

The provider used an enabling approach to risk management that supported people to have choice and control, while keeping them safe. The provider supported people to live ordinary lives and take positive risks without unnecessary restriction.
 

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 home was clean, well maintained and adapted to meet people’s needs. The provider managed key safety risks, including fire safety. Records showed an up-to-date fire risk assessment, personal emergency evacuation plans and regular drills and system checks. Gas and electrical safety certificates were current, and the provider kept records of legionella controls. Managers completed environmental audits and tracked actions to reduce risks and maintain a safe setting.

People and relatives described the home as tidy, comfortable and safe. Staff carried out daily checks to identify hazards and acted when they found issues. We saw examples of the provider making practical changes to reduce risks and support people’s needs. This included reviewing risks after incidents and making adjustments to help people move around safely. The provider also assessed the need for window restrictors and had plans to install them where required.

The environment supported people to live safely while maintaining dignity, privacy and comfort. The provider’s development plan included improvements designed to enhance wellbeing, such as creating sensory spaces and an allotment. There was a homely, enabling environment that reduced distress and supported people to live as ordinary a life as possible.
 

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 service had enough staff with the right skills to meet people’s needs. Rotas showed named core teams that supported continuity, and managers had clear arrangements for night cover. The service kept agency use to a minimum and used induction and handovers to support safe working when temporary staff were needed. Staff told us they had enough time to provide care, and people and relatives described consistent support.

The provider completed safer recruitment checks, including identity checks, references and Disclosure and Barring Service clearances. Staff completed mandatory training, and records showed all staff had completed Oliver McGowan learning disability and autism training. The provider assessed staff competence for medicines administration, and staff described shadowing and induction before working independently. Managers maintained supervision and appraisal records, and staff said they felt supported and able to raise concerns.
 

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 home was clean and hygienically maintained. The provider used colour-coded cleaning equipment and cleaning schedules for communal areas, bathrooms and bedrooms. We observed staff using personal protective equipment (PPE) appropriately, and hand hygiene facilities were available throughout the premises. Staff had access to PPE, and the provider monitored stock levels. Spill kits were accessible, with clear guidance for staff. The provider managed laundry and waste safely, and staff completed food hygiene checks, including monitoring fridge temperatures.

The provider had up-to-date infection prevention and outbreak management policies. Staff explained how they would respond to an outbreak and how they would share concerns with the right agencies when needed. Vaccination offers were documented, and the provider made reasonable adjustments for people who declined or needed alternative approaches. Managers completed infection prevention and control audits regularly. The service also had an up-to-date external infection prevention and control audit and an action plan was in place to address improvements identified.
 

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.

Each person had a medicines file that brought together key information staff needed to give medicines safely. This included hospital passports, consent records, mental capacity assessments, risk assessments and easy-read information about medicines. Support plans gave staff clear, step-by-step guidance on how and when to give medicines, including what to do if a person refused. PRN protocols were in place, and information sheets explained the purpose and possible side effects of medicines.

The provider stored medicines securely in locked cupboards and checked room temperatures daily. Staff transported medicines safely in locked boxes when taking them to people’s rooms. Medication Administration Records (MAR) charts were completed accurately, and managers carried out regular audits to check records and follow up any concerns. The provider also aligned MAR directions with care plan guidance for seasonal and topical medicines and recorded pharmacist involvement and review arrangements for covert administration.

The provider supported safe practice through training and competency checks. Staff completed online training and then had competency assessments before administering medicines. Staff told us managers investigated any errors and provided retraining and reassessment where needed.

The provider involved people in decisions about medicines where possible and used mental capacity assessments and best interests decisions when people could not consent, including for covert administration.