Mira Social Care

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

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 as requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to, people’s safe care and treatment and the ways people’s medicines were managed safely.

This service scored 62 (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 were encouraged to reflect on practice and learn from day-to-day incidents. The registered manager reviewed minor issues raised during routine care tasks and used these as opportunities to reinforce good practice and prevent recurrence. Learning was discussed through regular meetings, informal daily contact and supervision, which supported open communication and helped staff understand how to improve their approach. Because the service was small, learning was shared promptly, and adjustments to practice were made without delay.

Feedback from families and findings from spot checks were used to identify where staff required further guidance or development, contributing to a growing culture of shared 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 received care plans and verbal briefings when new people joined the service. They were informed of health needs, backgrounds, preferences and risks. Staff reported managers held meetings and ensured they reviewed plans before supporting the person.

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 different types of abuse and monitored for signs through behaviour, physical presentation and environmental cues. They described escalating concerns to managers and felt confident doing so. Staff had completed safeguarding training and used learning to notice injuries, distress, or behavioural changes. Relatives expressed trust in staff and said they felt comfortable raising concerns; staff were described as respectful and attentive.

The provider did not always ensure risks were understood, documented or managed consistently, meaning staff did not have reliable written guidance to support safe decisions.

Risk assessments were often outdated or incomplete and did not reflect known risks, including dementia related changes, catheter care needs, mobility fluctuations or falls related safety measures. This limited the provider’s ability to ensure risks were mitigated in a planned, structured or consistent way.

Staff involved people and relatives in day‑to‑day risk decisions and adjusted support when needs changed, using observation to identify distress, fatigue, disorientation or reduced mobility. Families contributed important information about triggers and early warning signs, which helped staff adapt support in real time. However, because several risk assessments had not been updated to match detailed care plans, staff relied heavily on verbal updates and real‑time judgement rather than accurate documentation. This created inconsistency and meant risks were not always managed using an evidence‑based or clearly guided approach.

Following our feedback, the provider updated some risk assessments and provided evidence

The provider did not always ensure environmental risks were identified, documented or managed consistently, meaning staff did not have reliable written guidance to support safe environments.

Several environmental and fire risk assessments were outdated and did not reflect changes in people’s homes or known risks. Important falls‑related safety measures such as restricting stair use, providing supervision and relocating a person’s bedroom were included in the care plan but missing from corresponding risk assessments. This meant leaders did not maintain an accurate overview of risks in people’s homes.

Staff were vigilant in practice and checked for hazards including clutter, spills, poor lighting and unsafe equipment. They reported concerns promptly and ensured hoists and walking aids were stable and safe before use. However, because risk assessments were not consistently updated, staff relied heavily on observation and verbal reporting rather than accurate documentation. This created inconsistency and reduced assurance that safe environments were maintained in a planned and evidence‑based way.

Following our feedback, the provider updated some risk assessments and provided evidence.

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.

Staff were supported and had the skills and training to provide safe care. They described clear induction processes and effective shadowing, with 1 staff member telling us they shadowed other staff for about a week. Leaders were accessible and provided regular supervision, reflected in the comment “My manager communicates well and supports me.” Staff reported manageable workloads and confidence in raising concerns.

Staffing arrangements helped ensure people received safe and consistent care.

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 understood when to use PPE and how to dispose of it safely and told us there was always enough available. One staff member said, “I have enough PPE. I know when to wear it and how to dispose of it.” They followed guidance during outbreaks by contacting managers, wearing PPE and recording actions. Staff also described clear steps they would take if infection was suspected, including calling the office immediately, following infection‑control procedures, and documenting everything.

The provider did not ensure medicines were managed safely, and staff did not have reliable guidance to administer medicines consistently.

Records were incomplete, contradictory and did not reflect people’s current medicines which increased the risk of omission, or incorrect doses. Medication administration records (MARs) were inconsistent across paper and Excel formats, and essential topical medication administration records were missing. Some discontinued medicines remained listed in care plans, while other prescribed items were recorded incorrectly or omitted entirely.

Documentation did not keep pace with people’s changing clinical needs, meaning staff had to rely heavily on verbal updates instead of accurate written instructions. This created avoidable variation in practice and reduced assurance that medicines were given as prescribed. Because of these gaps, medicines management did not support safe administration or provide a clear audit trail.

Due to the seriousness of these failings, the service was in breach of regulation relating to safe care and treatment.

Following our feedback, the provider updated the medicines documentation and reported plans to implement an electronic medicines management system to strengthen oversight and accuracy.