Millcroft

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 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. They listened to concerns about safety and investigated and reported safety events.

Systems and processes were in place to identify where things had gone wrong. Accidents and incidents were reported, recorded and analysed to identify any patterns or trends so actions could be taken to reduce the risk of reoccurrence. Lessons learnt were effectively communicated to staff to drive improvements. We observed staff meeting minutes, where falls had been discussed, and the actions staff were required to take to reduce the risk of falls and keep people safe.

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 registered manager told us they completed an assessment prior to people moving into the service to ensure staff could meet their needs. Records relating to people’s care needs were stored on an electronic care system which allowed information to be easily shared, for example, when people were attending hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

People told us they felt safe. One person said, “I feel safe because of the staff, if I have any concerns, I’d go to the office, but I haven’t needed to.” Staff completed safeguarding training and were able to describe how they would recognise signs of abuse. People appeared relaxed in the presence of staff.

Records showed most staff had completed training on the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Care records contained information relating to capacity and staff knew which people needed support with day-to-day decisions.

The provider worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health, safety and welfare had been assessed and covered risks relating to areas such as falls, medication and choking. Where equipment had been identified as needed, this was in place. Records were reviewed and updated when needs changed. Staff explained their understanding of people’s associated risks and how to mitigate these to support people safely.

The provider had systems in place to ensure the building and equipment was maintained and records kept of all checks, audits and external visits within the service. The environment was clean and well maintained.

People had the equipment they needed to keep them safe which was regularly checked to make sure it was working correctly. Each person had a personal emergency evacuation plan to guide staff on the support they would require in the event of a fire. Staff received training in fire safety and regular fire drills were undertaken to ensure staff were competent in the event of a fire.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs. People and their relatives told us there were enough staff to meet people's needs. One person told us, “There’s enough staff you can usually find someone no problem” and a relative said, “There are staff constantly around, they [staff] are about when I visit in the lounge”.

Staff told us they felt supported and had one-to-one meetings with their line manager and regular staff meetings.

The provider had systems in place to ensure safe recruitment practices were followed. Relevant and appropriate recruitment checks, such as the Disclosure and Barring Service (DBS) were in place. The DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Newly appointed staff completed an induction programme and shadowed experienced staff before they were able to work independently. Staffing levels were calculated using a dependency tool.

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.

Regular audits were undertaken to ensure areas of the home were maintained to a high standard. Policies were in place in line with current guidance for staff to follow. Staff also received training to support with infection prevention and control (IPC). Staff told us they had access to personal protective equipment, and we saw this being used appropriately.

People and relatives felt the home was clean and tidy. They told us, “Staff are very good with the laundry” and “It is beautiful and clean, they [staff] do a monthly deep clean of the room which I’m happy about”.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored and administered safely. Staff had received medication training, and their knowledge and competency assessed. Where people were prescribed ‘as and when required’ medicines protocols were in place to guide staff on how and when to administer these. Regular medicines audits were undertaken and areas for improvement were identified and actions put in place.

We observed where people were prescribed medicinal patches, the sites of application were recorded and rotated appropriately.We discussed our findings with the registered manager. When we returned, they informed us they had made changes to how these were recorded and arranged for staff to receive training around recording.