Majestic Healthcare Ltd

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

People were supported to receive safe care. Care plans and risk assessments were in place and reviewed when needed. Medicines were managed in a safe way. There were enough safely recruited staff who had the knowledge and skills to support people. The environment was safe, and infection control practice was managed in line with national guidance. There were processes in place to create a positive learning culture.

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 relatives raised no concerns with the learning culture within the service.

The registered manager, who is also the provider spoke about the learning since the last inspection and how they had used this to make improvements to the service. They told us how they had improved the systems to monitor care and the communication with people and their relatives. Staff confirmed they were aware of changes that were being made and felt involved.

When incidents or safeguarding concerns had occurred, there was a process in place to review these and identify any learning. This learning was shared with staff.

People and relatives raised no concerns, they told us they felt part of the admission process and were involved with their initial assessment and care plan design when they started using the service.

The registered manager and care co coordinators talked us through the initial assessment process. They told us how they went out to review people, when they started using the service, how they would develop a care plan and review this with the person or their relatives once they had started using the service. Staff felt the assessments identified people’s needs well.

As part of this assessment, we asked for feedback from the local authority and the integrated care board. The feedback was generally positive. No concerns were identified with people’s safety.

There were systems in place to ensure people’s needs were assessed and then reviewed when they started using the service.

People and relatives raised no concerns about safety. Everyone was happy with the care they received and felt safe.

Staff and leaders were aware of safeguarding procedures and the action to take if they felt people were at risk of potential harm. They told us they had received training and what action to take if they were concerned about someone.

There were systems in place to ensure any safeguarding concerns were identified, reviewed and investigated. The processes ensured they were reported to the local safeguarding team when needed.

People and relatives raised no concerns with how risks were managed. One person said, “I have loads of equipment and staff know how to use it.”

The registered manager and staff told us improvements had been made since our last inspection. The registered manager told us individual care plans and risk assessments were now in place for people. They told us these were reviewed monthly or if changes occurred. Staff were aware of the care plans that were in place for people, they felt they had the detail needed to keep people safe. Staff were aware of individual risks to people, the levels of support they needed and any action they may take to keep them safe.

There was a system in place to ensure people had care plans and risk assessments that were reflective of their current needs. These were reviewed regularly or when changes had occurred.

People and relatives felt staff respected their homes/environment and kept it safe. A relative confirmed that staff used personal protective equipment (PPE) and disposed of everything properly in a bin outside of their property. They said they always disinfected everything when they had finished and said it’s often tidier when they finished than when they came in.

Staff told us the care coordinators assessed the safety of people’s homes as part of the initial assessment process. One staff member said, “If there is anything we should know about there will be a risk assessment in place to make us aware.”

There were processes in place to ensure that environmental risks had been considered. People risk assessments in place that considered these risks.

People and relatives were happy with the staff and the calls they received. One person said, “Sometimes it varies, but if they’ve been held up, they call and let me know”. Another person said, “9/10 they’re here on time but they’ll let me know if they’re going to be later”. When asked about training another person said, “They’re trained well and I can’t fault them, if they’re stuck, I put them right”.

The registered manager shared their concerns when they had to stop using a selection of their staff. They told us, “People and relatives raised concerns as they were happy with the staff and they had been using them a long time.” They told us there were enough staff available for people and were trying to ensure people received a more consistent staff team moving forward. Staff confirmed they were unable to support people in their homes until they had completed the relevant recruitment checks. Staff told us they had received training. One staff member said, “We have completed a lot of training, I have done the mandatory training alongside other training like stoma care and epilepsy.”

There were systems in place to ensure there were enough staff available to support people. Staff were allocated their rotas in advanced so they knew who they would be supporting. People had a contingency plan recorded in their care files to identify their risks and support if there were staffing difficulties. Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so. Staff had received training to ensure they had the relevant knowledge and skills to support people. This included training that was relevant to people’s individual needs.

People and relatives raised no concerns with infection control. One person said, “They always wear protective gear.”

The registered manager told us infection control was considered and staff used and had enough personal protective equipment available. Staff also confirmed this to us.

There were processes in place to ensure staff protected people from the risk of cross infection.

People and relatives raised no concerns with how their medicines were managed. One person said, “The staff give me my medication”. They went on to say, “They’ll tell me if things are running low and I’ll let my daughter know”. A relative told us, “The care staff dispensed my relations medication. If anything is running low the carers would call and let me know.”

The registered manager told us there was an improved system in place to monitor medicines to ensure they were safely administered. They said, “The audits have helped us have a better oversight of this and this has improved.” Staff told us they had received training, and their competency was checked to ensure they were safe to administered medicines. A staff member said, “We have a spot check on medicines so someone will come out who we don’t know to watch us.”

People received their medicines when needed. We saw people had ‘as required’ guidance in place for staff to follow. People received these medicines in line with this guidance. Staff had received training, and their competency was checked to ensure they were safe to administer medicines to people.