Mowbray 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 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. Accidents and incidents were investigated and analysed. Staff discussed incidents in handovers and meetings in a way which focused on openness and improvement. Audits routinely generated actions, which staff completed and monitored to embed safer practice.

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. Staff escalated concerns promptly, such as behaviour changes, weight loss or swallowing difficulties, and worked effectively with GPs, epilepsy nurses and other professionals.

When people moved into the service this was done in a planned and phased way to minimise distress to the person and their relatives. One relative told us, “The staff came to see [person] first before they moved in. The staff were very good and there was great support for [person] when they transitioned.”

People received support during transitions, including hospital appointments and periods of admission. Care plans included essential information to guide staff, and where changes occurred, staff ensured records were updated accordingly.

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 safeguarding and felt confident to raise concerns. They told us they would escalate issues promptly and believed leaders acted quickly. People and relatives said they felt the service was safe. A relative said, “I’ve got no concerns as the home is well-run and I can’t imagine [person] living anywhere else.”

The service worked with external professionals where safeguarding-related risks were identified, including around behavioural and clinical needs, physical health issues and mental capacity. Incident reporting processes ensured the management team reviewed events and followed up with people and families.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Deprivation of Liberty Safeguards (DoLS) authorisations were in place for people where appropriate.

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. Individual and environmental risks had been identified and managed. Care plans outlined how best to mitigate each risk and guide staff to support people to remain safe. These were reviewed regularly to ensure the information remained accurate and complete. Staff supported people to take positive risks where appropriate. Staff involved people and relatives in decisions about their care, including choices about daily living, activities and personal preferences.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Safety checks of the premises and equipment were completed regularly and appropriate action was taken when needed. Procedures were in place for emergency situations and these were reviewed and updated regularly.

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 staff on duty and people’s needs were responded to promptly. Staff were recruited safely and there was a stable staff team which ensured consistency. Staff members confirmed they had opportunities for training and development and they felt supported. Staff described a culture of positive teamwork, and relatives said staff appeared skilled and knowledgeable.

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 followed safe infection prevention and control practices and used personal protective equipment (PPE) to help prevent the spread of infections. Staff had completed infection prevention and control training. The environment was visibly clean. A relative said, “The home is always clean and spotless.”

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.

Systems were in place to make sure people’s medicines were administered safely. Medicines that needed to be given at specific times were given correctly. Where people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose such as pain relief, information on how these medicines should be administered was person-centred and was reviewed regularly. Records were kept regarding how effective such ‘when required’ medicines had been, in line with good practice.

Medicines were stored securely and temperatures were recorded for the medicine rooms and fridge to ensure medicines were stored within appropriate guidelines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people's medicines were reviewed by prescribers in line with these principles.