Shrewsbury Road - Max Potential

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.

People were involved in their care. Relatives told us they were included in people’s care, knew how to raise concerns and were confident they would be listened to.

The service had a system in place for recording and reviewing incidents and accidents, although only one had occurred at the time of the inspection and we saw details were recorded about anyactions taken. The registered manager told us they would complete trends analysis to monitor any re-occurring incidents if they were to happen.

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.

People and their relatives told us staff communicated effectively when required with external health and social care professionals. The service had a summary of people’s needs and requirements, which was accessible to staff and relevant professionals. This meant a safe transition between services, such as, emergency admission to hospital. One relative said to us, “The manager facilitated a really smooth transition for us at the start.”

People’s needs, and care requirements were detailed within their care plans and risk assessments, and hospital passports were also used for each person. Relationships between the service and external professionals were established. Health and social care professionals we spoke with were complimentary about the service. One professional said, “The manager is open to feedback and is engaging with all of our officers.”

People living at Shrewsbury Road and their relatives said they felt the service was safe and were happy living at the home. Information was displayed around the home about who people could speak with or contact if they had any concerns about their safety.

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.

There hadn’t been any safeguarding incidents at the home, although staff were aware of what might constitute a safeguarding concern and any signs they would look for and said they had competed the relevant training. One member of staff said, “Safeguarding is about protecting people from exploitation, neglect and abuse. If there were concerns with a person’s finances, there would need to be safeguarding referral.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In [care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found DoLS applications were made to the local authority as required and staff understood about the legislation.

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 who used the service had individual risk assessments in place relating to the care and support they received. These included risks relating to the home environment, road safety, accessing the community and the use of equipment. People’s care plans also covered any specific risks relating to falls/mobility, eating and drinking, and skin.

Where any risks were identified, control measures were detailed about how these needed to be managed. For example, ensuring people were wearing appropriate footwear and that the environment was free from obstacles to prevent any falls.

We noted that one person had previously smoked in their bedroom and staff had said they could sometimes smell smoke. This had been clearly explained to the person and they now smoked in a designated area in the back yard. We spoke with the registered manager about ensuring a risk assessment was clearly documented regarding this.

People who used the service and relatives were involved with risk assessments where possible and we saw the service were responsive when there were any changes to people’s circumstances. One person wasn’t comfortable crossing roads on their own, although was able to make the choice of whether to do this with support from staff. Several people living at the home were diabetic and were encouraged to eat lower sugar food items which we saw were readily available in the kitchen area, although staff also respected people’s individual choice in this area.

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

Although the home was a relatively old building, the home had modern furnishings and fittings to ensure the environment was well-maintained. For example, walk-in showers/bathrooms had been installed which were spacious and could facilitate wheelchair use if needed. The home had an external yard area with seating which people could use then the weather allowed.

There were regular visual checks of the environment to make sure it was safe and free from hazards. Essential servicing had taken place such as the maintenance of gas, water and electricity. A fire risk assessment had been completed which was reviewed regularly. Staff told us they felt the environment was well-maintained and that if repairs were required, they were done quickly.

Safety procedures were in place for any visitors to the home. For example, the front door was kept locked and people were asked to show identification and complete the signing in book on arrival.

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.

Staffing rotas were in place and demonstrated how many staff were available to care for people. The feedback we received from people who used the service and relatives was that staffing levels were sufficient. One member of staff said, “Usually there is just one member of staff in the building, but for only three people, that is enough. If people need support to go out on their own, such as to an appointment, then staffing is increased.”

Staff were recruited safely, with appropriate pre-employment checks carried out before staff started working with the service which included Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had opportunities to learn, and any poor performance was managed appropriately. Staff told us they were asked to complete these checks when they first applied for the position.

Staff told us they received enough training to support them in their role, including Oliver McGowan which is specific training relating to people with a learning disability. Staff supervisions and appraisals took place where staff could discuss their work in a confidential way. A member of staff told us, “We have enough training, additional training can be provided if there is something specific to people’s needs.”

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.

We found the home was clean and tidy throughout. Staff received infection control training and were predominantly responsible for cleaning tasks, they tried to involve people living at the home with this where possible. Cleaning schedules and check lists were in place covering all areas of the home.

A weekly audit was carried out which covered infection control and focused on areas such as PPE and if enough hand washing soap was available. A relative said to us, “The environment always feels homely and is clean.”

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.

Medicine administration records showed people received their medicines as prescribed. People who had been prescribed medicines on a when required basis had written plans in place to inform the care staff of how and when it was appropriate to administer these medicines.

People were supported to go out and visit friends and family. The service had procedures in place to account for the medicines whilst they were away from the service.

All medicines were stored securely. Staff that administered medicines had completed safe management of medicines training and had undergone an assessment to check their competency to administer medicines safely.

Medicines audits ensured people received the medicines when they needed them.