Miranda House

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 changed to 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.

The provider was in breach of the legal regulation relating to safe care and treatment.

This service scored 56 (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.

Records demonstrated accidents and incidents were clearly documented, and lessons were learnt to minimise a reoccurrence. Learning was undertaken through discussions within reflective practice sessions and staff handover meetings. Staff involved in any accident or incident were always asked to undertake a self-reflection exercise and complete additional training if needed.

The registered manager told us transparency was important to them, so accidents and incidents were reported to the local safeguarding team and the Care Quality Commission as required. Records showed people’s relatives were informed when safety events occurred. There were effective systems to identify any trends or patterns in accident and incidents. This ensured action was taken to recognise and mitigate any emerging risks.

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.

The registered manager told us the service had good relationships with a range of healthcare professionals. This included GPs, specialist nurses and the Care Home Liaison Team. They said they always assessed people on their discharge from hospital, so liaised with hospital staff as needed. Records confirmed the service worked with a range of staff within multi-disciplinary teams. This included speech and language therapists (SALT) and the tissue viability team.

We received positive feedback from involved health care professionals. One professional told us, “When we offer advice following assessment we will review after a week or 2 and I have found that the advice/changes [we] have advised will always be put into place. They will contact us if they are unable to do this or if they have any concerns.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Care planning was insufficiently detailed to demonstrate how best to support people at times of distress. This included potential triggers, or any de-escalation techniques staff should use. Care plans identified staff should speak calmly, clearly and use reassuring tones to make the person feel comforted, safe and cared for. However, there was no explanation of what this meant in practice. This did not ensure people’s distress was managed effectively and in accordance with individual needs.

There were repeated incidents where a person entered into other people’s personal space in the communal lounge. This distressed some people. We saw a person telling them to “Shut up” and another person gently pushing them away with their leg. When we informed a staff member about this, they told us the person was regularly unsettled and walked around a lot. Staff did not recognise the impact this had on others, which increased the risk of an altercation.

However, people and their relatives did not raise any concerns about safety and gave positive feedback about the service. Comments included, “It’s wonderful here,” “The staff are excellent,” and “They’re all brilliant, they speak nicely.”

Staff received regular training in safeguarding and knew how to recognise and report signs of abuse. They said they would raise any concerns with the registered manager or registered nurses and were confident appropriate action would be taken.

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 that the provider was able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications and urgent authorisations in a timely manner.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were not always supported to move safely, which increased the risk of them sustaining harm. For example, we observed staff assisting one person to move from their bed to their armchair using an unsafe ‘under arm’ manoeuvre. Another staff member pulled on a person’s wrists to help them to stand. Staff did not ensure a wheelchair was secure whilst assisting another person to transfer from a wheelchair to their armchair. The registered manager told us all staff had received training in moving people safely, so knew not to use such manoeuvres. They told us they would ensure staff completed their training again.

Staff had not always considered risks to people’s safety when undertaking housekeeping tasks. For example, one staff member was using the carpet cleaner in a doorway at lunchtime, when people were walking through to the dining room. Another staff member was vacuuming in the corridor but left a trailing lead behind them, across the doorways of people’s rooms. These practices increased the risk of people sustaining an injury through trips and falls. The registered manager told us they would address these incidents with staff and monitor such practice.

However, staff had assessed other risks people faced, and care plans identified what action was needed to enhance safety. For example, people’s risk of developing skin damage had been assessed and control measures including repositioning and any equipment used, were identified. Overall, care charts demonstrated these position changes had been completed in line with care plan guidance.

People’s risk of malnutrition was regularly assessed. Records showed the GP was informed following any weight loss, and action was taken. Staff told us this included fortified foods and drinks to promote additional calorie intake. For those people at risk of choking, care plans provided clear guidance on how to reduce the risks, and what to do if a choking episode occurred. Staff safely supported people with their food and fluids during the inspection.

Records demonstrated risks to people were reviewed within daily handover and clinical governance meetings. This ensured all staff were up to date with any action required to enhance safety.

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

There were systems to enhance the safety of the environment. This included audits and health and safety checks including the water, lighting and fire alarm systems. The registered manager told us all actions from the audits were being undertaken or had been completed.

Windows had restrictors to minimise people falling from a height and there were keypad locks to restrict unauthorised access to certain areas of the home. Cleaning substances were securely stored, and fire exits were clear of obstacles. However, there was a hot pipe which ran above the skirting board in one person’s bedroom. This person was at risk of falling so there was a risk of them sustaining a burn if they fell against it. The registered manager told us they would ensure the pipe was covered immediately.

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

During the inspection, staff responded to people’s call bells in a timely manner. However, we needed to use the call bell on 3 separate occasions as people needed assistance, but staff were not aware of this. This increased the risk of people sustaining harm. The registered manager told us their staffing tool identified there were enough staff to meet people’s needs, but they would review staff deployment in response to these incidents.

There was mixed feedback about staff deployment. Some relatives were concerned about the high use of agency staff as they felt they had limited understanding of their family member’s needs. Other comments included, “They’re often short at weekends” and “Occasionally, there are delays in completing tasks such as changing clothing, removing breakfast trays or administering medication.” One staff member told us staffing levels sometimes felt insufficient for the level of people’s needs. Other staff said there were enough staff but also raised concern about the impact of using agency staff.

The registered manager said they were currently recruiting to cover staff sickness and annual leave. This recruitment had been successful and the use of agency staff was reducing.

Staff had access to a range of training to help them do their job effectively. This included mandatory topics such as safeguarding, and those related to people’s needs. However, records did not show all agency staff were up to date with their training. This increased the risk of these staff delivering unsafe care.

Staff received daily informal support and had regular individual meetings with their line manager to discuss their performance.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed some toilets in people’s ensuite facilities were not clean, and there were odours in some people’s bedrooms and in corridors. Whilst there were cleaning schedules, these toilets were not cleaned in a timely manner and remained the same at lunchtime. The registered manager told us the odours were due to some people’s continence, but more focus was needed to ensure a more pleasant environment for people.

However, other areas within the home were generally clean. There were regular infection prevention and control audits and a policy for staff reference as required.

Staff had received training and were knowledgeable about minimising the risk infection. They wore protective clothing whilst supporting people with their personal care and when serving food and disposed of soiled linen appropriately.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Instructions for the administration of some medicines were not clear. This was because insulin doses for two people were not clearly documented on the medicine administration record. In one case, the diabetes care plan had not been updated to reflect the revised dosage. There was inconsistent recording of tablet numbers of a variable dose anticoagulant and missing information in the person’s care plan. Some people were prescribed topical medicines, but there were no corresponding body maps to support staff to apply them safely and effectively.

There were shortfalls with the storage and recording of some medicines. For example, the register for those medicines that required more secure storage did not always match the recorded pages. There was a discrepancy of one medicine, whereby two capsules were missing. Staff later found them loose and returned them to their original packaging. This raised concern about accuracy and traceability and indicated poor audit oversight and ineffective checking processes.

The refrigerators which stored medicines were not locked, which meant the medicines were not secure. One refrigerator, located on the ground floor contained an inhaler which was contrary to the manufacturer instructions. There was also a urine sample, which should not have been stored alongside medicines in the refrigerator.

Staff checked allergies and administered medicines in line with prescriptions, but medicines were routinely marked as administered before they were given. This contradicted with the provider’s medicines policy. Guidance was generally available to staff regarding the administration of ‘as required’ medicines. However, the dose limits in the system did not always match the prescribing instructions. Whilst administering medicines, the staff member carried the home’s telephone. This meant they were disturbed by incoming calls, which was a distraction and increased the risk of error.

However, the GP regularly reviewed people’s medicines and records showed medicines were given as prescribed. Staff were knowledgeable about the medicines they administered. They received regular training in the safe management of medicines and had their competency assessed.