Moorlands Lodge Care 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 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 in relation to the ways people’s medicines were managed.

This service scored 62 (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.

People told us they were happy living at the service and felt safe and well cared for. One person said, “I think it’s ok and they do their best to accommodate us strange people”, “I feel quite at home, quite comfortable” and “I’m extremely happy. I have friends, comfort and am near to my home. I am very happy.”

Incidents and accidents, safeguarding concerns and complaints were recorded on the provider’s electronic system. These were reviewed, discussed and analysed to determine any underlying causes or trends and identify any actions required to improve the service.

Staff told us regular meetings were used to share information about any incidents along with any learning and we saw evidence of this. Staff knew how to report and document any incidents or accidents. Lessons were learned when things went wrong.

The leads and supervisors were encouraged and supported to undertake root cause analyses when incidents or accidents happened, so they understood how to identify and reduce risk. There were daily care ‘catch ups’ with nurses and management to share any concerns and identify any actions needed.

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.

People told us they felt safe living at Moorlands Lodge Care Home. Relatives stated they were informed when their family members required support or treatment from different agencies.

The staff team and managers told us they worked well with other professionals to ensure continuity of care, including when people moved between different services or required temporary stays in hospital. The registered manager told us, “A hospital pack is prepared for each person should they need to be admitted to hospital. This includes 24 hours of care notes, so they know and understand people’s needs. Paramedics are given medicines administration records (MARs) to know what medicines people are on. Reception sends an email out to everybody to let them know someone is in hospital.”

Healthcare professionals told us they had a good working relationship with the service and communication was good.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

People told us that in general they felt safe and protected from abuse. Their comments included, “I feel very safe, I’m so bossy I’d be telling them what to do”, “I don’t see any risks of any kind, so I feel safe” and “I do [feel safe], they are very thoughtful and kind.” A relative agreed and said, “I think my [family member] is safe, I don’t have any worries.”

Records showed that safeguarding concerns were reported appropriately. The service was working alongside the local authority safeguarding team to ensure processes to manage risks were in place and monitored. Staff received safeguarding training and demonstrated an understanding of the different types of safeguarding, reporting procedures and the whistle-blowing policy.

The registered manager had processes in place to ensure everyone was informed and worked together to keep people safe. They told us, “We have the whistleblowing policy in staff areas so they are informed. We discuss with staff any low-level concerns or safeguarding that need to be raised. We have “10 minutes at 10” which is when all the heads of department meet and discuss any events, reporting and information they need.”

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

People said staff knew their needs and met these safely. There were effective processes in place to help ensure risks to people were assessed and mitigated.

Risk assessments were completed and were comprehensive and regularly reviewed. They were accessible to staff in areas including mobility, nutrition, mobility, falls and specific health conditions. Where required, referrals were made to external professionals such as speech and language therapy, community mental health services and the district nursing team. Advice and guidance provided was followed to minimise risks to people’s safety.

One person was at high risk of falls and pressure injuries. They also needed supervision when drinking hot fluids due to cognitive impairment and the risk of scalding. We saw individual care plans and comprehensive risk assessments were in place for each of these risks, tailored to the person’s needs and regularly reviewed to support safe, effective, and person-centred care.

Another person was at high risk of infection from a biliary drain site. A biliary drain is a medical device used to relieve blockages or obstructions in the bile duct. We saw a biliary drain care plan was clearly documented, and staff were trained in infection prevention practices to mitigate this risk.

Incidents and accidents were recorded and contained details such as a description of events leading up to the incident, action and response and post incident analysis. Each report also highlighted what has been put in place to prevent re-occurrence. Following the incident, an action plan was put in place and care plans and risk assessments were reviewed.

Personal emergency evacuation plans were in place for each person. These contained detailed information about each person and the support they required to safely evacuate the building in the event of a fire or other emergency.

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

The management team and staff worked together to help ensure faulty equipment or trip hazards were identified and addressed promptly. We saw that safety checks were completed daily and weekly in all areas of the home to ensure safe systems were in place. These included water temperatures, fire safety checks and kitchen equipment.

Emergency procedures were well-documented and regularly reviewed, with staff showing clear understanding of their roles during various scenarios. Equipment used to support people was suitable, well maintained and stored securely. The provider had an up-to-date emergency plan in place to help ensure people were supported in the event of an emergency.

During the inspection, we observed safe moving and handling practices being consistently followed. Staff demonstrated kind and compassionate care.

People’s bedrooms and apartments were personalised with photographs and items belonging to them and were homely and clean.

Although the provider told us they made sure there were enough qualified, skilled and experienced staff on duty, some people felt there were not enough staff available at times, and they had to wait for support. The provider made sure staff received effective support, supervision and development. The staff worked together well to provide safe care that met people’s individual needs.

Most people thought there were enough staff to support them and meet their needs. However, a small number of people felt there were not enough staff available and they sometimes had to wait for support. Their comments included, “I do have to wait. I needed somebody today when I was in the dining room as I was unwell with an upset stomach and needed to wait a long time”, “I have to tell you they are very short staffed, and really not brilliant” and “I like to get up when I want, but I just have to wait and wait. If only they would tell you the night before, then I wouldn’t mind waiting so much, but it’s just the not knowing.”

The provider used a dependency tool to help ensure there were always enough staff to meet people’s needs. The staff rotas indicated they ensured the correct number of staff were deployed according to the tool. In addition, we looked at the call bell records which showed a 98% response to calls within 3 minutes. However, the registered manager told us they would address the concerns in relation to the feedback received without delay.

During our inspection, a person in their room was requesting support but there was only one member of staff in the lounge. They told us they could not leave other people unattended. We were unable to find another staff member and had to report to the registered manager’s office where a senior member of staff immediately went to support the person. The staff rota indicated there were enough staff on duty but they were all busy with people or were on their breaks. The registered manager told us they would address this with the staff team and would ensure this would not happen again.

The provider carried out checks on the suitability of staff before they started working at the service. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

Staff told us they were happy working at the home, felt supported and listened to. They said they received training that equipped them to do their job well and care for people and regular refreshers to ensure their skills were updated. Staff told us they received regular supervision and appraisals to support them in their roles and records confirmed this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People told us they felt safe from the risk of infection because premises and equipment were kept clean and hygienic, and relatives confirmed they did not have any issues with the cleanliness of the service.

Cleaning staff followed a cleaning schedule and used appropriate personal protective equipment (PPE). Care staff wore PPE when supporting people to help protect people from cross infection.

Appropriate systems were in place in relation to infection control. The provider ensured staff had access to PPE and were trained in the use of this. The provider’s infection prevention and control policy was up to date. Information about the risk of infection was shared appropriately with people using the service and visitors. The managers and senior staff carried out audits to ensure standards of cleanliness were good.

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

Although people told us they received their medicines safely and as prescribed, we found some concerns in relation to medicines management.

A person who had difficulties swallowing was advised to have their medicines crushed. Their electronic medicines administration record (eMAR) correctly listed these medicines. However, the risk assessment for this was out of date. Although the person’s needs had not changed, the registered manager agreed risk assessments should be regularly reviewed.

Another person’s eMAR record stated the specific medicines that could be crushed. However, on the day of our inspection, the senior on duty reported to us that they had been instructed by another senior member of staff to crush all other medicines the person was prescribed, and were following this instruction. Medicines that should not be crushed are specifically designed to work in certain ways and altering them can lead to overdose, reduced effectiveness, or serious side effects. This meant that this practice had taken place without the prescriber’s direction, and there were concerns that this could affect the effectiveness of the medicines.

Some medicines bottles/containers had labels that were not always legible. This may cause the dispenser to have difficulties reading important information or instructions.

Medicines audits were undertaken but were not always effective because they had not identified the concerns found during our inspection.

Where people were prescribed ‘as required’ medicines, we saw there were protocols in place to inform staff about the medicine and how to administer this in line with the prescriber’s instructions and the person’s needs and preferences.

Medicines reviews were carried out by the local GP. There was a process to report and investigate errors and incidents. Medicines were stored securely and at the required temperatures. Staff received training and were competency assessed to handle medicines safely.