Star Maris Healthcare Limited Also known as Star Maris Healthcare

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 service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Learning from accidents, incidents, complaints and other events was embedded in the day-to-day running of the service. The registered manager carried out quarterly accidents and incidents management reviews to look at trends and implement the necessary measures to mitigate risks. Staff meeting records demonstrated where lessons had been learned and how these were shared with the staff team. This indicated a safety culture focused on learning and improvement.

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 worked with people, their relatives and relevant health and social care professionals to plan and review care. Records demonstrated effective communication with other agencies, such as the local authority, and timely referrals, helping to maintain continuity of care and ensure people received appropriate support. Care records showed risks were identified and managed as people's needs and circumstances changed. People had hospital and emergency care plans, which guided staff to support safe transitions between services.

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 were alert to safeguarding requirements and understood their responsibility to report concerns internally, as well as escalating them to external agencies if needed. The provider had implemented appropriate systems and procedures to safeguard children, including a safeguarding children policy and staff training. Relatives told us people felt safe with the care and support they received.

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.

Risk assessments were clear, detailed and specific to people’s individual needs, circumstances and behaviours. Staff reviewed and updated them regularly, including following incidents, to minimise the risk of recurrence. Relatives reported that staff had built a good rapport with people, which supported the delivery of safe and person-centred care and support. Staff explained how they developed an understanding of people’s behaviours and what was important to them, enabling them to recognise potential triggers, tailor their approach and reduce risks.

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

Risk assessments included consideration of environmental hazards in people’s homes. Where children using the service accessed the community and public facilities, such as playgrounds, staff followed appropriate guidance to mitigate risks. For example, control measures were identified to ensure a person was transported safely when accessing different locations.

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.

Overall, staff attended to people on time. They notified people or their relatives if they were running late. Relatives told us staff completed all the required tasks and demonstrated competence in their roles. There had been no reported missed care visits.

Staff had access to a range of training courses, including training to support children and training relevant to people’s individual needs. They received continuous support through supervision and appraisals.

The provider carried out safe recruitment checks to ensure only the suitable candidates were offered employment. Staff recruitment files contained a range of pre-employment checks, including DBS checks (police check) covering both adults’ and children’s barred lists, staff employment histories, identity checks and employment references.

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 wore personal protective equipment when providing personal care. People’s care plans contained guidance on maintaining good hygiene, including handwashing prompts. The provider carried out regular unannounced spot checks, which included checking that staff were adhering to infection prevention and control guidelines.

The provider had systems for managing medicines safely and in line with people’s needs, preferences and abilities. However, these systems were not always effective, as discrepancies were identified in medicine administration records (MAR) which had not been identified through audits.

Staff used an electronic MAR system to record when people had taken their medicines. However, there were instances where staff were unable to sign the MAR or signatures did not register correctly due to technical issues with the software. While staff usually completed a backup paper-based MAR in these circumstances, this was not always done consistently. Weekly medicines audits did not always identify or clarify these discrepancies. Following the assessment, the registered manager informed us of several actions they had taken to improve documentation, including reviewing their audit processes.

There was an issue regarding the prescribed instructions for a person’s laxative medicine, as the MAR instructions did not always reflect the circumstances in which it was administered. The registered manager discussed this with the person and their relative and sought clarification from the GP.

Staff were trained and assessed as competent to manage and administer medicines. People’s care plans contained clear information about their medicines, including their purpose, potential side effects and instructions for administering ‘when required’ medicines.