Mavern House Nursing Home

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 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.

People and their relatives told us they felt supported by the staff team and felt safe. Staff provided support in a safe and calm way. Staff followed safety guidelines as required. Comments from people and their relatives included, “Yes, I feel safe here. I feel comfortable” and “I think staff would ring me and tell me if anything happened. They have rung about other things. And if there is anything I want to know they will tell me.”

Staff were encouraged to report incidents. They told us, “If someone fell and had a head injury, I would call for help and make sure the resident was comfy. Then the nurse assesses them, and maybe they would need to go to hospital” and “I would press the buzzer, and then wait for the nurse to see if they said it was OK to move the person.” Staff told us they were informed when incidents and accidents occurred. Comments included, “This will be shared with staff during handover, so we might be told to do more checks, monitor for signs of head injury etc. It comes up on our hand-held devices for example to be aware of sensor mats. I then pass it on to everyone I’m working with” and “We are told what’s happened in the past 24 hours during handover, and we can check care records if needed.”

Incidents and accidents were reported. However, actions from incidents were not always transferred into care plans to inform staff how to reduce the risk of an incident happening again. Incidents were investigated and we saw examples in records. However, there was not always clear evidence of how lessons learned were shared with staff. Although discussed at meetings, some staff told us they did not always receive minutes of any meetings they were unable to attend. We discussed this with the registered manager during the assessment and they told us they would review the process.

People and their relatives said the service supported them to attend external appointments such as hospital appointments. People told us they had access to GP services. Comments included, “They [staff] got the doctor straight out this morning [when person was unwell]” and “If you don’t feel well you stay in your room. They [staff] come into your room and check if you are OK. They get the doctor. You just tell the nurse; they are very good.”

Staff told us they worked well with health and social care professionals and had developed good working relationships. Staff told us they supported people at hospital appointments if needed.

We spoke with health professionals who work with the service. They said they had a good relationship with the staff. One professional said, “We have a trusted relationship with staff here. I have been coming here for several years now, and we have a good relationship. They [staff] are good at planning ahead; they are on the ball. Even if someone is not my patient, they will use their initiative and ask for my advice.”

There were clear processes to ensure people’s current information was safely shared with health and social care professionals. A member of staff from the local ‘Managing older people team’ visited weekly. Staff told us they could access advice and support outside of the regular visits if needed. Records showed people were reviewed by health professionals when required. For example, records showed people were reviewed by a speech and language therapist (SALT) if swallowing concerns were noted by staff. The service used a nationally recognised tool to assess and respond when people’s condition deteriorated. This is a key element of safety and improving outcomes.

People told us they felt safe. Comments included, “Yes, I feel safe. The staff are very good.” One person’s relative said “[Name] is the ‘wellest’ [they] have been for a long time; better health wise and more mobile.”

Staff were trained and understood their responsibilities to keep people safe from avoidable harm and abuse. One staff member said, “If I saw bruising, I would take a picture on our hand-held devices and click handover, so the nurse sees it, and I also report it. We have to do this to look out for abuse or harm” and “If we saw new bruising, we would take a photo and tell the nurse. We have to tell the nurse because it might be abuse. If someone told me a member of staff did it, I would raise my concerns and go higher if needed.”

We observed staff interacting with people in a safe way. Staff were observed to be following people’s risk management plans and using equipment when needed. Staff were engaging with people in a respectful manner.

There was a safeguarding and whistleblowing policy that gave staff clear guidance to follow in the event they needed to refer any concerns to the local authority. Referrals had been made to the local safeguarding team appropriately. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with DoLS. This meant people’s rights were fully respected. The manager kept a record and tracker of DoLS applications and authorisations, and this was regularly reviewed to make sure authorisations were current.

People did not raise any concerns about this quality statement.

Staff were aware of risks to people’s safety, for example, choking and skin damage. Staff told us they knew what to do if someone choked, for example. Staff knew how often people required support to change position and how to do this safely. One staff member said, “If people are at risk of pressure sores it is all written in the care plan. Most people where I work need 3 hourly repositioning. The phone will alert us if we haven’t done it, and it also tells us if we need to offer people more to drink.”

We observed people sitting in the communal lounges on both days of our assessment. We saw staff were sat with people, talking with them, or engaging them in activities. When people needed staff support to move around, we saw staff walking with people.

Potential risks to people’s health and welfare had been assessed and risk assessments had been reviewed regularly. We discussed a discrepancy in the information for 1 person in relation to the use of drinks thickener to reduce the risk of choking, and this was resolved during our assessment. Pressure relieving equipment we looked at was not always set correctly. Some air mattresses were set digitally, and the screen locked but some were manually set. Mattresses set manually were not always set correctly. We discussed this with the registered manager during the assessment and they informed us they were in the process of replacing all manually set mattresses. The registered manager told us they would review how staff monitored the settings on these until they were replaced. Some people had been assessed as being at risk of malnutrition. Plans included information for staff such as food preferences, frequency of monitoring people’s weight and any specialist advice that had been sought. When people were having their food and fluid intake monitored, records showed people were provided with enough to eat and drink. ‘Hydration stations’ were in place around the service, and we saw that people used these to help themselves to drinks and snacks. Bruises and skin tears had been reported and appropriate action taken in response.

People did not raise any concerns about the environment. One person said, “[Staff] have told me I can do gardening and what I want with the patio in the summer.”

The registered manager told us there was an ongoing plan to ensure the building was well maintained. They told us the stair carpet was due to be replaced the week after our assessment. Other areas of the building were being reconfigured to make best use of the space for people to use.

The environment was visibly clean and well maintained. There was an electronic system and staff could report any maintenance requirements. The registered manager demonstrated how they were able to monitor actions taken. There was a large central courtyard area for people to use in warmer weather. Equipment that we looked at was fit for purpose . For example, wheelchairs and walking frames were in good condition and clean.

We reviewed records of checks carried out to ensure the premises were safe. This included gas, electrical and fire safety checks. Regular checks of equipment were carried out. Personal evacuation plans were in place. These had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency.

None of the people or relatives we spoke with raised any concerns about staffing levels. People told us staff responded to call bells in a timely manner. People and their relatives spoke highly of the staff. Comments included, “The staff are lovely. Even the boys, and the ones on nights are nice” and “The girls are perfect, I can’t fault them. The nurses are good. The cooks are good and if you don’t like something, they say, ‘what would you like?’ and they’ll bring it.” Another person said “The nurses are very compassionate. Very kind.”

Most staff raised no concerns about staffing levels. Staff comments included, “Yes, we have enough [staff]. At weekends, we don’t have management on site, but [deputy manager] practically lives here and we do have on call” and “Sometimes if people go off sick, we might be short. I would not say we are ever understaffed though. We will ring round and get help in if we can.” One staff member said, “Sometimes we are a bit short in the afternoons; it would be nice to do an evening pamper if we had more staff.” Staff said they were trained to carry out their roles. One staff member said, “We have had brilliant training; we had first aid training recently, it was great. The training is really good and supports my way of learning.” Another staff member said, “If there was something I'm not familiar with, I can ask for extra training if I need it.”

Call bells were answered in a timely manner. The service audited response times to call bell alerts to help ensure that appropriate numbers of staff were in place. Staff did not appear rushed and took their time with people. Staff had the skills to meet people’s physical and mental health needs. Nurses told us they attended training specific to their roles, including medicines management.

Safe recruitment processes were followed. There was a process in place for staff to receive regular supervision. There was oversight of staff training at manager and senior manager level. Staff were incentivised to complete their training.

People using the service, and their relatives did not share any concerns about this quality statement. Comments included, “They [staff] wear gloves and pinnies all the time” and “They [staff] use gloves a hell of a lot.”

Staff had been trained in infection prevention and control. Staff knew when and why they needed to wear personal protective equipment (PPE). One staff member said, “We put PPE on before going into the person’s bedroom, take it off after personal care and then put in a yellow bag in the sluice room. When we had people with Covid-19 we wore face mask, aprons and masks inside their rooms. And we do lots of handwashing.”

We observed staff wearing aprons when supporting people with meals . We saw stocks of PPE around the building for staff to use.

There were effective processes to prevent and control infection. Housekeeping staff were on duty 7 days a week. There was enough PPE available for staff to use. Regular infection prevention control audits had been carried out. These included audits of the environment, equipment and staff spot checks. Relatives told us the service was always clean. Staff encouraged people to be involved in keeping their home clean .

People using the service did not raise any concerns about this quality statement.

Staff who administered medicines had received up to date medicine training and had their competency checked.

Protocols for medicines that had been prescribed on an as required [PRN] basis were not consistently available. The PRN protocols were not consistently person centred and did not inform staff when and why people might need their additional medicines. When some PRN's had been administered by staff, there was not always information recorded to show why they had been administered and the effectiveness had not been recorded. This meant it would be difficult to assess how well medicines were working. We discussed this with the registered manager who told us they would review all PRN protocols. There were systems to order, store, administer, record and dispose of medicines. Medicine incidents were reported and investigated.