Menna 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.

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 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 recorded and reviewed so any trends or patterns could be identified. Feedback to staff of any changes to people’s care following an incident were communicated in handovers and staff meetings.

Staff had supported people to identify goals and develop skills, information about what worked well and what did not work was shared between the staff team to help develop consistent approaches and improve outcomes.

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.

The service communicated with other agencies to help ensure continuity of care. Hospital passports contained essential information to inform hospital staff how best to support people if they needed to be admitted to hospital. An external professional described management as, “approachable and receptive to discussions about the person’s care.”

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.

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's capacity was assessed in line with the MCA and, where people did not have capacity, decisions were made in their best interest. An external professional described staff as, “Proactive and considerate in promoting independence and reducing restrictions.”

Staff had completed training in safeguarding and the MCA. They understood their responsibilities under safeguarding and reported any concerns to management. They were confident any concerns would be dealt with but were aware how to escalate issues outside of the organisation if needed.

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.

Any risks were identified and recorded with guidance for staff on how to manage risks. When restrictions were necessary to keep people safe these were proportionate and the least restrictive option. The provider was pro-active in encouraging and supporting staff to follow a positive risk management approach. A member of staff told us how some restrictions had been removed. They commented; “It was good seeing that happen and being part of that process.”

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

Checks of utilities and equipment were regularly carried out by external contractors. Staff completed weekly and monthly checks such as water temperatures and fire safety equipment. One person described to us what action they would take if the fire alarm went off. They were clearly confident and told us they had taken part in fire evacuation drills.

Adaptations had been made to the environment to support people’s safety. For example, hand-rails had been fitted on the stairs and one person’s bath had been replaced with a wet room as they were finding it more difficult to get in and out of the bath.

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.

New staff were recruited safely and completed an induction before starting work at Menna. There were sufficient staff to meet people’s needs and enable them to take part in any pastimes or hobbies they enjoyed.

Staff received regular supervision and the registered manager was planning yearly appraisals.

A training matrix showed staff had completed training in relevant areas including supporting people with a learning disability and autistic 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.

Staff supported and encouraged people to keep their accommodation clean. Staff meeting minutes showed staff had been reminded of the need to keep shared areas clean at all times. Staff had access to Protective Personal Equipment (PPE) when carrying out personal care.

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.

People received their medicines as prescribed. Protocols had been developed for medicines to be given ‘as required’. This helped ensure staff were consistent when administering these medicines. People received their medicines in a safe way and medicines were kept in people’s rooms. This allowed people to take their medicines in private.

The service used an electronic Medication Administration Record (MAR) system. Two members of staff completed medicine rounds. This helped reduce the risk of errors.

People were supported in line with STOMP, an NHS campaign to stop the inappropriate prescribing of psychotropic medications to individuals with learning disabilities and autism.

Regular medicine reviews were completed to help ensure prescribed medicines remained necessary and appropriate. A relative told us; “[Name] seems to be doing really well after a reduction in their medication so that's good news.”