Maer Lane

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 inspection we rated this key question requires improvement. At this inspection has remained 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.

This service scored 59 (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 did not always have a proactive and positive culture of safety based on the effective review of all potential significant events. Lessons were not always learnt to continually identify and embed good practice. For example, the provider did not evidence they effectively reviewed all incidents involving people to ensure staff followed best practices to safely and effectively support them. Although the management team did review accidents and other significant events to identify if anything could be done differently this was inconsistently applied.

However, the management team and staff members were aware of the potential of a closed culture. A closed culture is an environment where poor practices go unchallenged. We found Maer Lane was an open and supportive environment where people, relatives, healthcare partners and staff could freely express their views.

The service 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 had individual communication and needs passports which were reviewed when there was a change in need. These went with them to appointments or assessments to support continuity of care and equal access to services. We saw instances where people needed to access alternative healthcare services owing to unforeseen circumstances. Staff worked with the person to ensure the transition was seamless and supportive.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately. One person said, “I feel quite safe here. I feel better then I have in other places and this is home.” People were supported by staff who had been trained in safeguarding and knew what to do if they suspected something was wrong. Staff members told us how they would report any concerns which reflected best practice.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, 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 appropriate assessments and applications had been made in line with the recommended procedures whilst still supporting people to live the lives they wanted. Any restrictions in place were authorised, proportionate and the least restrictive.

The provider did not always work well with people to understand and manage risks. The provider did not always provide care to meet people’s needs that was safe. Not all known risks had been assessed to ensure people remained safe. For example, where people were living with diabetes there was no specific risk assessment identifying the impact of this medical condition on the person. There was a lack of information available to staff regarding how to effectively identify a change of condition or what to do in the event of an emergency. However, when we raised this with the management team, they reviewed the information available and circulated this to staff. In other instances, people had assessments of risk based on their individual circumstances. One relative said they felt their family member was safe and their welfare was a top priority for the staff and the management team. They had no concerns at all about any risks.

The service had not always detected or controlled potential risks in the care environment. For example, we saw free standing furniture had not been assessed for risks of toppling, there were incorrect restrictors on windows and in some areas of the home signage to direct people in the event of an emergency was missing. However, once these were identified the provider acted to address the potential risks and made physical alterations to reduce the potential for harm. The provider did complete other checks to ensure people lived in a safe environment. This included regular fire prevention system checks.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide safe care that met people’s individual needs. People and relatives told us they were supported by enough staff to effectively support them. We saw people interacting with staff in a relaxed and friendly way. People were supported to direct their day and staff responded positively to them. Staff had been safely recruited. People were supported by staff who had received training to support those living with a learning disability or autism.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Although staff members followed recognised best practice to minimise the risk of communicable illnesses in some instances, the physical environment hampered this. For example, we saw some compromised flooring and toilet seals, compromised shower edging sealants with evidence of mould and exposed plaster where electrical items had been replaced. These issues prevented staff from being effective with their cleaning. We raised this with the registered manager who had identified these were part of an improvement plan but recognised this was overdue. They committed to make these improvements. Other areas of the home were clean and tidy and supported staff members to be effective with their practices.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Although the management team were aware of the principles of STOMP (Stopping The Over-Medication of People with a Learning Disability, Autism or Both), these were not effectively applied. For example, when people received PRN medicines the management team did not review the preceding incident or circumstances to ensure this was the correct action for the situation. They did not identify any trends or patterns to the use of PRN medication which put people at risk of having their medication misused. Although we found no evidence this had happened in this instance, the management team needed greater oversight to ensure people were safe. In other instances people received their medicines safely and as prescribed by a trained and competent staff team.