Mary's Home

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 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.

The service learned from mistakes and took action to improve people's safety. The registered manager reviewed accidents and incidents records. Accidents and incidents were analysed to see if people's care needed to be reviewed. Reviews of people's care included referrals to appropriate healthcare professionals. Where an issue arose, appropriate action was taken to reduce the risk of reoccurrence. This meant the service was able to learn from incidents that arose.

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.

Healthcare professionals told us that engagement with the provider was good. Communications were effective and regular and people’s health benefitted from good working and co-ordinated relationships with them. One healthcare professional we spoke with told us, “I visit people here regularly and I have good communication with the staff team here. This helps us all meet the needs of people more effectively and in a good coordinated way”. We saw procedures were effective and people’s health benefitted from good working and co-ordinated relationships with healthcare professionals.

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.

People said they felt safe at Mary’s Home and they were well supported by staff. Comments from people included, "The staff here have been really supportive to me. I feel safe here” and "I don't have any worries, I am pleased with the care I get here."

People were protected from abuse and improper treatment. The service had appropriate safeguarding procedures in place and staff received on-going training around identifying signs of abuse and the actions they should take. Staff understood their role in protecting people from abuse and their duty to report any suspicions of abuse. Where safeguarding concerns were raised the provider acted promptly and decisively to protect people. This included making safeguarding referrals to the local authority, notifying CQC and taking action to ensure people’s safety.

We checked whether the service was working within the principles of the MCA. We saw recent decision-specific mental capacity assessments for people who were suspected to lack capacity in specific areas. The registered manager demonstrated a clear understanding of what MCA assessments were and how they differed to DoLS. They showed us renewed DoLS applications made to the relevant local authorities, together with the local authority acknowledgement of receipt and were awaiting the outcomes. This meant staff were able to make decisions appropriately for people who did not have capacity to make them themselves.

Staff had received training in MCA and Deprivation of Liberty Safeguarding (DoLS) and told us about the core principles of the MCA and how this was used when supporting people.

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.

People were protected from avoidable harm or danger because risks for each person were identified and managed. Care records contained risk assessments about each person which identified measures taken to reduce risks as much as possible. These included risk assessments associated with people's nutritional needs, hydration, moving and handling, pressure sores and falls. People identified as being at an increased risk of skin damage had pressure relieving equipment in place to protect them from developing sores. This included pressure relieving mattresses on their beds and cushions in their chairs.

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

People said they were very happy living at Mary’s Home and they told us they felt safe and they liked their bedrooms. People told us it felt like home.

We saw the home environment was safe and maintained to a high standard. It looked and felt comfortable for people to live in. The whole building had been refurbished to a good standard. Communal areas were especially well laid out with some areas specifically designed for small groups of people to gather and other areas for larger groups of people. People were happy and there was a friendly atmosphere in the home when we visited. The provider recently received a 5-star rating for food hygiene last year. The kitchen had been recently completely refurbished and this has enabled the high standards to be achieved and maintained in the kitchen.

All services to the home were regularly maintained and checked for safety. We reviewed all the service’s safety certificates, such as for gas, legionella and electricity, and confirmed all the services met the required standards and had been deemed safe for use.

We saw evidence of audits and checks carried out to ensure the environment was safe. A fire risk assessment was in place, so staff were able to support people appropriately in the event of an emergency. Fire equipment was regularly maintained and serviced.

Comprehensive and regular environmental audits also checked for areas requiring improvement.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs

We observed that enough numbers of staff were present in the service and who knew people well. Relatives told us there were sufficient numbers of staff on duty to meet people’s needs. Comments received from relatives were positive and reflected a caring and responsible attitude that staff had in caring for their family members.

Staff received support through supervision. This included one to one meetings and team meetings. The registered manager and the owner acknowledged the frequency of these formal meetings did not meet the provider’s own policy to do with staff supervision. They agreed to implement regular six to eight weekly individual supervision meetings for every staff member. A new matrix was introduced immediately that set out every staff members’ forthcoming supervision dates. The registered manager also told us they were introducing a new supervision format that set out the agenda for supervision meetings and included the direct work staff undertook with people. These measures should ensure staff have the skills, knowledge and experience to deliver even better effective care and support.

Staff comments received, showed they felt appropriately supported by managers with their work. Staff told us they received training in core areas such as with dealing with distressed behaviour, safeguarding, first aid, infection control, the Mental Capacity Act, food hygiene, equality and diversity, epilepsy, autism and the safe administration of medicines. A training matrix was in place that evidenced staff received all the training referred to above. Accident and incident reporting processes were in place, understood by staff and maintained to date.

There was evidence of robust recruitment procedures. All potential staff were required to complete an application form and attend an interview, so their knowledge, skills and values could be assessed. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. There were systems in place to review staffing levels against people’s dependency, these were reviewed regularly and in line with people’s changing needs.

The provider assessed and managed the risk of infection effectively. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People’s relatives told us the home was always kept clean. We found there were appropriate cleaning schedules in place. Comments from relatives included: “The home always seems clean,” “The home is lovely, it is always clean, no nasty smells” and “The refurbishment has made this a really nice place to live.”

We undertook a tour of the premises and found them to be clean and free from infection. Inspection of fridges and freezers demonstrated food was labelled with opening dates as required. Appropriate cleaning schedules were in place and were carried out as required to help minimise the risk of infections.

Staff told us they received training in infection control and food hygiene, which was regularly refreshed, and which helped them maintain good practice.

The home had effective infection control policies and procedures in place that were in line with best practice guidance. The registered manager carried out a monthly audit of staff infection control practices. We reviewed the last 6 audits and saw they were comprehensive in the coverage of areas reviewed and where issues were identified they were addressed appropriately and action taken to reduce the likelihood of reoccurrence. Staff we spoke with knew the relevant policies and were able to describe how they ensured the risks of infections spreading were properly controlled.

There was a pleasant, homely atmosphere in the home with no unpleasant odours.

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 told us that staff supported them with their medicines and as prescribed by their GP. Staff told us they were responsible for administrating people’s medicines and were fully aware of the actions they were required to take when there were specific considerations such as with people's PRN medication. Staff told us they regularly liaised with health professionals for advice. Health professionals we spoke with confirmed this. They told us staff in the home liaised appropriately with them and this they said contributed to good coordinated joint work. This has helped to keep people healthy and safe.

Staff were aware of the actions to take with people's medication, for example with PRN medicines. This included speaking with medical professionals for advice.

Appropriate policies and procedures were in place for staff to follow to ensure the safe administration of medicines to people. Staff received appropriate training. Regular medicines audits took place to identify any areas for improvement. We reviewed the most recent of these audits. Competency checks were completed for staff responsible for administering medicines.