My Pillar Limited

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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’s systems did not fully consider learning when things went wrong. There was a reporting function in the electronic records system which enabled a review over time of all incidents and accidents. However, this was not in use at the time of the inspection. This meant when incidents occurred there was no review to consider broader patterns or trends of incidents. The registered manager told us that they believed the individual reviews undertaken did assist them with identifying learning, but they would work to consider the reporting function and how this could be used going forward. People and their relative’s felt staff were supportive when accidents occurred. Examples were shared of staff coming back to check on people after a hospital visit following a fall and sending staff out to support people when relatives have alerted to a fall. Staff could describe how they supported people if there was an accident including ensuring this was fully documented in an incident report. The registered manager told us they reviewed all incidents and these included reviews of people’s risk assessments and care plans when needed. Any learning from incidents was shared with staff.

The providers’ systems did not consistently ensure safe systems of care, in which safety was managed or monitored and ensure continuity of care. The registered manager told us they had a new electronic care records system in place; however, some aspects of the system were not working effectively or had not been fully embedded. For example, where risks had been identified for people who were at risk of falls or had skin integrity issues these were not consistently referenced in relevant care plans. Where assessments had identified needs these had not always resulted in a specific care plan, for example where people had diabetes there was no care plan in place to guide staff on how to support them. There was no documented consent to care plans in the system and medicines records were not consistently completed. The registered manager was aware of these issues and was working to make improvements.

The provider had systems in place to safeguard people from abuse. Staff understood how to protect people and support their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People felt safe using the service and felt they were able to raise any concerns. A relative told us, “I feel if anything happened [person’s name] would speak staff or the manager as they get on really well with them.” Staff had received training in recognising abuse and could describe how they would report any concerns. The registered manager had a process in place to ensure any concerns were reported to the appropriate body.

The provider had systems in place to understand risks to people and guide staff on how to meet people’s needs and keep them safe, however, these were not consistently linked to care plans and sometimes lacked detail. Where someone had a falls risk assessment in place this was not linked to the guidance and care plan for mobility support and manual handling. Another person had a hoist in use, and the care plan lacked detail on how this should be used. This meant records required improvement to ensure they were accurate, despite these records issues staff were knowledgeable and were able to describe how they kept people safe. People were supported to use equipment safely. A relative told us, “The staff have been trained to use the hoist safely and to date no accidents have occurred.” People were supported to access equipment to manage risks to their safety. A person told us, “The staff made a request for a hospital style bed, this means [person’s name] is able to get up more easily.” People and relatives also shared examples of the support staff gave them to manage risks associated with their health and they felt this was managed well to keep people safe. Staff could describe peoples risks and the guidance in place to support people. For example, staff told us about how they used equipment, supported people to minimise the risk of falls and worked with people who could become anxious and distressed. Care plans had guidance for staff and were developed following risk assessments. The registered manager told us all risk assessments and care plans were reviewed annually and at any point when something changed with the person, reviewing records more frequently could help ensure they are detailed and linked to relevant care plans.

The provider detected and controlled potential risks in the care environment. They ensured equipment, facilities and technology supported the delivery of safe care. People told us staff supported them to maintain a safe environment. A person told us, “The staff do leave the home clean and tidy and will point out any issues they might feel are unsafe e.g. removal of rugs. When the staff first started, they carried out a full inspection to ensure safety of the staff as well as my relative.” The registered manager told us they completed risk assessments. We saw these were included in people’s care records and staff were aware of the content and could describe how they used the information to keep people safe. The risk assessments considered pets, trip hazards and fire safety and guided staff on how to reduce the risks.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together to provide safe care that met people’s needs. People had mixed views about the timing of calls, people told us staff almost always arrived on time; however, some people told us the staff did not always stay for the full call time. A person told us, “The staff are usually on time and if they are going to be late someone will ring us and let us know. They do stay their fulltime.” Whilst a relative told us, “[Person’s name] are supposed to have 30 mins but on one occasion staff were in and out in 5 minutes, other times they were out within 12 minutes.” The registered manager told us they had some people who did not have sufficient time allocated for their calls and they were liaising with the local authority to address this. The registered manager had a system in place for staff to log in on arrival and at the end of the call. This was monitored daily and prevented missed calls and enabled any late calls to be alerted to people. Staff told us they received regular updates to their training and support from the registered manager with regular meetings and supervisions in place, records supported this. The registered manager told us they had a system in place to safely recruit staff. There was a recruitment policy in place and records showed this had been followed.

The provider had systems and processes in place to protect people from the risk of infection. People were protected from the risk of cross infection. A person told us, “The staff always wear masks, disposable aprons and gloves. They remove their shoes and put slipper shoes on before entering the bathroom.” Staff told us they had received training in infection prevention control. They understood the importance of using protective equipment and explained this was aways available. The registered manager told us they had a policy in place which was up to date and following guidance on preventing the risk of cross infection.

The provider had systems in place to record when people had received their medicines. However, records were not always completed accurately to show people had received their medicines on time. The registered manager reviewed the records every day and ensured people had received their medicines and adjusted the records to show this. This meant improvements were needed to ensure medicines were recorded accurately in the system. The registered manager told us they were aware this needed to be improved and were working on this with staff. They had also made contact with the system provider to undertake additional training in using the system more effectively to have oversight. People told us they were supported to take their medicines as prescribed. A person told us, “They give me my medication at the right time and they know what medications I am on and when I require them. They record it on their phones.” Staff told us they had received training in how to administer people’s medicines and records we saw supported this.