United Response - 29 Mayfair Avenue

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 continue to be 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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. A member of staff told us, “I would tell the manager straight away if abuse ever happened here. I know they have to then contact the local authority, the CQC, and if appropriate, the police as well.” People told us they felt safe living at the care home. Typical feedback included, “Yes, I do feel safe living here,” “[name of relative] is kept safe at the home. We have confidence in the manager and staff to deal with any incidents” and “I am confident the manager provides a safe environment for our [name of family member] to live. We have never had any reason to be worried about abuse or neglected there.”

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had made improvements to the way they managed risk as we had recommended at their last inspection. They had introduced an electronic monitoring system which automatically notified the registered manager and staff when peoples risk management plans needed to be reviewed and updated. This meant peoples risk management plans were now sufficiently detailed, person-centred and accurate.

Staff ensured potential risks people might face were mitigated, so that people remained safe when taking part in activities and events of their choice. Staff were aware of the potential risks people might face and the steps they needed to take to prevent or safely manage them. People told us staff knew how to keep them safe. A person told us, “They [staff] do know how to look after me,” while a relative said, “All staff are aware of [family members name] limitations and are able to provide assistance as necessary.” An external care professional added, “All my clients who live in the care home have person-centred risk assessments and management plans in place and staff receive comprehensive training and know how to keep manage risk and keep people safe.”

People’s electronic care records contained up to date, sufficiently detailed and accurate information. Staff told us they always followed people’s risk assessments to enable people to take reasonable and acceptable risks. One member of staff said, “I like the new electronic care plans because they’re easy to follow and access, and will let you know immediately if anything needs changing.” The providers new electronic IT system ensured risks to people were continually assessed, monitored and reviewed.

The service did not always ensure adaptations and reasonable adjustments were made to the environment to meet people’s individual needs.

The care homes environment was a safe, clean and comfortable place for people to live. People living in the care home, their relatives and staff all confirmed this. However, most people, including the registered manager, agreed some aspects of the care homes interior layout, décor and furnishings needed improving. A relative told us, “They do need to improve the care homes interior décor and make the large sunlounge/conservatory area, which doubles up as an activities room, cooler in the summer months.” A member of staff added, “There is scope to improve the overall decor of the home. The provider is aware some rooms need a lick of paint and the old kitchen units definitely need replacing with new ones.”

Aspects of the care homes interior layout, décor and furnishings required improving, including making the ground floor conservatory a more hospitable place to enjoy social activities, repainting in various communal areas where paint had peeled off and replacing the old worn out units in the kitchen, the damaged sofa in the main lounge and missing tiles in the first floor bathroom.

We discussed these environmental and infection control issues with the registered manager at the time of our inspection who agreed some aspects of the care home had not been well-maintained and were well overdue refurbishing. The provider had developed a time specific action plan to improve the care homes interior layout, décor and furnishings within the next 3 to 6 months.

The premises were kept clean. A relative told us, “The home is clean and tidy in all the areas where my [family member] has access to.” An external care professional added, “The service always looks very clean and tidy.” The care home was free of obstacles and hazards which enabled people to move safely around the care home.

There were effective arrangements to monitor the safety and upkeep of the premises. Regular checks were completed to help ensure the safety of the home’s physical environment and fire safety equipment. This included regular health and safety checks on the homes electrical, gas and water systems. Staff told us they had clear guidelines available to help them deal with emergencies. In relation to fire safety, we saw emergency evacuation plans were in place to help staff evacuate people in an emergency.

The service 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.

The provider had made improvements since our last inspection as we had recommended. The providers electronic monitoring system now automatically notified the registered manager when staffs training needed to be refreshed.

Staff were well-trained to meet people’s needs and were encouraged to continually improve in their role. Staff received a mixture of e-learning and in-person practical and theoretical training, which was routinely refreshed as frequently as staff required it including, competency-based assessments. A relative told us, “Staff are well-trained and have vast experience and skills.” A member of staff added, “I receive all the training I need to meet the needs of all the people who live in the care home. It’s always relevant, there’s plenty of it and its constantly being up dated. I would say we’re a pretty competent and well-trained bunch working here as a result.”

Newly employed staff were subject to a probationary review and records showed staff received an induction to their role and ongoing training and support to ensure they could meet the needs of people living in the care home.

Staff had ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might need. Staff had regular individual and group meetings with the registered manager. A member of staff said, “We have regular supervision meetings with the manager. I do feel 100 percent supported by him and my fellow co-workers.”

Staffing levels matched the staff duty rota on the day of our site visit. People told us the care home was always adequately staffed. Typical feedback included, “This home has good staffing ratios to ensure optimum client support. The service has 2 staff during the day and one sleep-in staff at night to ensure appropriate levels of client support,” “Staff coverage is usually sufficient and we as a family find it very reassuring that staff changes are rare” and “Whenever I visit the care home to see [name of family member] there are enough staff on duty to support his needs. He has a good relationship with all of them.” Staff confirmed there was always at least 1 member of staff on duty in the care home at night and a minimum of 2 or 3 during peak periods of activity during the day. The service operated an on-call system at night when suitably trained and experienced managers and senior staff who lived in close proximity to the care home took it in turns to be available when needed to respond to an emergency situation. The registered manager told us the service had not needed to use the night time on-call system in the last 12 months.

The provider continued to operate safe recruitment practices and only fit and suitable staff were employed to work at the care home. Staff files contained evidence of robust recruitment checks including application forms where gaps in employment were explored, professional and personal references, right to work and identity checks. The provider maintained a recruitment tracker to monitor staff recruitment and completed Disclosure and Barring Service (DBS) checks. This helps employers make safer recruitment decisions by processing requests for criminal record checks.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The provider had improved how they managed medicines on behalf of the people living at the care home as we had recommended at their last CQC inspection. Medicines monitoring checks and audits were now carried out at regular intervals by the registered manager to ensure medicines were safely managed and well-organised. Medicines stocks, balances and records showed people consistently received their prescribed medicines as and when they should. People told us staff supported them to take their prescribed medicines as and when they should. A relative said, “My [family members] medicines are always administered correctly.”

Care plans included detailed guidance for staff about how people needed and preferred their medicines to be administered. Staff received relevant training and their competency to continue managing medicines safely was routinely assessed. This helped staff remain clear about their roles and responsibilities in relation to the safe management and administration of medicines. There were regular checks conducted of staff’s medicines management practices to ensure they remained competent to manage people’s prescribed medicines safely. An external care professional told us, “This service carries out regular medicines checks to ensure my clients consistently receive their medicines safely and as prescribed.”