Dimensions The Mulberries

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

Some aspects of the service were not safe. We observed an incident where staff did not follow guidelines when administering medicines. We also found some medicines records were not clear or accurate. We identified some risks had not been identified or mitigated, including cleaning products which were not properly secured. We discussed these with the registered manager, and they took action to rectify these and put in place strategies to prevent reoccurrence. They sent us assurances and evidence of this action. There were enough suitable staff, and they were well trained and supported. People lived in a well maintained and clean environment. The staff worked together to learn when things went wrong and make improvements to the service.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us the staff contacted them if anything went wrong or if there were accidents. They were happy with the information they received, and the action staff took.

Staff told us they were involved in learning when things went wrong. They discussed accidents, incidents and other concerns together. They explained they were given training and support to help improve practice.

All accidents, incidents and adverse events were recorded and investigated. However, investigations and learning were not always recorded clearly. For example, a staff member had identified a concern regarding medicines shortly before our visit. The registered manager was able to tell us the action they had taken but this had not been clearly recorded or shared with staff to learn from this. Following our visit to the service, the registered manager made improvements in this respect and sent us evidence of this. The registered manager shared information with senior managers who analysed these and checked appropriate action had been taken. Managers from different services managed by the provider, met with each other to discuss shared learning from their own services.

One person we spoke with had recently moved to the service. They told us they were happy with the support they had received with their move. Their relative also told us the move went well and the person was supported to stay in touch with friends from their previous home.

Staff explained they worked with other professionals to help people access healthcare services.

We did not receive feedback from external partners regarding this. No concerns were identified.

There were systems to help people move to the service. These included personalised transition plans. For example, arranging visits to the service and spending time with people who lived there. Staff also spent time with people before they moved to the service, providing care and support in their previous homes. The staff created hospital passports and health action plans. These described people's health and communication needs and were designed to be accessible for other professionals so they could provide personalised care when people accessed these services.

People's relatives and the person we spoke with told us they felt safe. They knew what to do if they had concerns about safety.

Staff told us they had received safeguarding training. They knew how to recognise and report abuse.

We observed an incident where someone was placed at risk because the staff did not follow correct procedures relating to use of some equipment. We discussed this with the staff member and the registered manager and were assured the incident would not be repeated and staff had learnt from this. The registered manager sent us evidence of action they had taken following our visit.

The systems to ensure people were safe were not always followed. There was not always clear information to show how safety concerns had been investigated. We spoke with the registered manager and were assured by the provider's actions. However, these had not always been clearly recorded. For example, when staff had identified medicines errors.

Relatives told us they thought risks were well managed.

Staff told us they had training to safely care for people. They knew how to use equipment and how to support people to move in a safe way. Some people were at risk of choking or needed specialist diets including texture modified food and drinks. The staff demonstrated a good understanding of people's individual needs and how to keep them safe.

Except for the 1 incident we witnessed, we saw staff cared for people in a safe way. They provided appropriate support and made sure people were well informed, safe and comfortable.

Some of the processes for identifying and mitigating risks had not been followed. We found 2 cupboards containing potentially dangerous cleaning products had not been locked. The risk of people accessing these was low. However, best practice indicates these products should be stored securely. The registered manager sent us evidence this was addressed immediately following our visit. We also identified that the fridge had exceeded safe maximum temperatures for over 1 month. There was a food hygiene risk associated with food being stored at the wrong temperatures. There was no indication people had been harmed. Following our visit, the registered manager rectified this and put-up notices to remind staff to take action if temperatures were not correct. The staff had assessed risks to people's safety and wellbeing. These assessments included management plans to show how people would be kept safe and how to encourage people to be independent and try new things.

People's rooms were personalised. For example, the staff had positioned mirrors in 1 person's bedroom to reflect the garden when the person was in bed because they found this relaxing and enjoyed looking at the trees. People were able to make choices about décor and were involved in making decisions about the environment.

Staff told us they carried out checks to make sure the environment and equipment were safe. The registered manager told us there had been improvements to the environment with areas which had been refurbished and decorated. There were plans for further decorations and improvements.

The environment was suitable to meet the needs of people who lived there. Accommodation was on a single floor and all rooms were wheelchair accessible. There was a range of equipment suitable to meet the needs of people who had physical disabilities. There were rooms with sensory equipment to help provide relaxation and stimulation. The home was well lit and ventilated.

There were systems to help ensure equipment was well maintained and regularly serviced. The staff carried out regular checks on safety including fire safety. The staff had developed personal evacuation plans to describe the support people needed in the event of an emergency evacuation

Relatives told us they thought there were enough staff. They said the staff were well trained and knew how to support and care for people.

Staff told us they felt well supported. They told us the service was well led and they had the information they needed. They explained there were good systems for communication and teamwork. The registered manager told us they thought the staff were ''amazing.''

Staff were attentive and people's needs were being met.

There were enough suitable staff deployed to care for people. Staff vacancies were covered by regular temporary staff who were familiar with people and the home. There were systems to ensure only suitable staff were recruited. These included a range of checks, an induction and training. Staff had access to a range of training and opportunities to meet with their manager to discuss their work and the service. The registered manager had organised for specialist training where they identified the staff needed this. The staff told us this was useful. Staff had undertaken training to understanding about learning disabilities and autism.

Relatives told us the environment was clean.

Staff explained they had undertaken training about infection prevention and control.

The environment and equipment were clean.

There were suitable procedures for ensuring cleanliness, infection prevention and control, waste management and laundry.

People did not always experience safe administration of medicines. We witnessed a member of staff providing medicines to a person. They did not follow the guidance on how to do this and this placed the person at risk. The registered manager took action following this incident to make sure the person was safe. They checked with medical professionals and they arranged for additional training for the staff member concerned to ensure the mistake did not happen again.

Staff told us they had undertaken training about safe handling of medicines. The registered manager assessed their competencies and knowledge. The registered manager told us they were arranging additional training for staff.

Some medicines administration records (MARs) were not accurate. They included dressings and medicines which were no longer in use. Some of the current dressings were not recorded on MARs. Staff did not always record the amount of stock medicines being held at the service. The registered manager took action to rectify this following our visit. There was no indication people had received inappropriate care and there were no adverse effects from this. There had been improvements in the way medicines were managed and concerns we identified at the last inspection had been met. The provider liaised with the pharmacist and healthcare professionals to help manage medicines in a safe way. People's medicines were regularly reviewed.