North Bay 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 Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, medicines and staffing.

This service scored 31 (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 did not have a proactive and positive culture of safety. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. The provider had not been effective in identifying areas of improvement within the home environment to reduce the risk of people injuring themselves. People were exposed to the risk of harm because risks to their health and safety had not been adequately assessed, and not all that was reasonably practicable had been done to mitigate such risks. The system for reviewing incidents and accidents was not being used effectively and therefore the management team were unable to demonstrate how they had learned from incidents or mitigated on-going risk. For example, where a person had fallen down the stairs, a review of the incident had not taken place to ensure risks were mitigated for the person, and potentially others. Another person had choked, but no review had taken place to ensure all steps had been taken to prevent further choking episodes. Falls were not being analysed for themes and trends to prevent a recurrence.

The service did not always make referrals to the appropriate partners when required, in a timely manner. For example, dementia intensive support teams, when people were experiencing periods of distress as a result of living with dementia. The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. This meant that people continued to be at risk of harm.

Hospital passports were in place for use in circumstances when people were transferred to other facilities so staff could support people effectively.

The provider did not 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 and take actions to prevent avoidable harm. The area manager did report concerns appropriately to the local authority safeguarding team; however, they did not always take action to keep people safe immediately. For example, we observed 1 person hit another in the dining room and found they had previously hit another person causing their nose to bleed. The person was observed to be alone in the dining room at times with no staff present, meaning further incidents could occur putting other people at risk of harm. An incident occurred relating to sexual safety between 2 people, but no risk assessments had been put in place which would identify triggers, de-escalation techniques and actions that could mitigate risks. Internal investigations were not undertaken where needed promptly.

People we spoke with told us they felt safe with the staff who provided their care; however, some people gave examples where staff were described as ‘rude’ and ‘curt’. Relatives felt their loved ones were cared for safely, giving positive examples of how staff had made a difference to people’s day to day well-being.

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 and supportive. The risks associated with people’s care were not managed in a safe way placing people at risk of harm. The management of the risks of people’s skin integrity was not managed in a safe way. There was a lack of guidance for staff in people’s care plans on how to reduce this risk, meaning there was a risk of people developing skin conditions or pressure ulcers. Other risks such as people’s risk of falling or risk of choking was not properly assessed and actions put in place to mitigate these risks.

‘Behaviour’ risk assessments and care plans in place for people did not always have sufficient guidance for staff on how to support them when they experienced periods of distress. There was a lack of information on what may trigger people to be distressed or how staff needed to respond when the person was directing their anxiety towards people and staff. This placed the person, staff and others at risk of harm.

We found accessible items across the service which could cause harm to people if ingested. This included bleach tablets, toilet cleaner, toiletries, and drinks thickeners. Drinks thickener if consumed can block the airway as it expands. This placed people at risk of serious harm, which could be fatal.

Following the inspection, we took urgent action to ensure the provider acted promptly to rectify immediate concerns.

The provider did not always detect and control potential risks in the care environment.The safety of the premises, such as bedrooms, were not robustly checked or managed to support people to stay safe. For example, in 1 person’s room, we found the window to be too wide, despite having a window restrictor in place. This meant the person was placed at the risk of falling from height with potentially fatal consequences. Another person’s bedroom led to a fire escape which had access to a staircase. The person was living with dementia and was mobile and therefore could have accessed the fire exit and fallen down the stairs without it being immediately obvious to anyone as it was within their own bedroom.

Risks to people’s safety in the environment had not been assessed, which meant that risks were not mitigated. For example, stairways were accessible to people who could fall and seriously injure themselves. One person had fallen on the stairs, but following this, no assessment of the staircase had been completed to consider the on-going risk of people falling.

There was a fire risk assessment in place, and fire drills were carried out, however, new fire evacuation equipment was recently provided so staff still needed training in how to use this. Further, new locks had been installed around the staircase following our inspection, some of which took time to open. As a result of our concerns we made a referral to the fire service and requested they visit the premises to ensure fire safety controls that were currently in place were safe.

Personal emergency evacuation plans (PEEPS) were in place for people, however, they were not sufficiently detailed and, in some cases, inaccurate, so we requested they were updated promptly. Most staff had completed fire training, however, 8 staff still needed to complete this. This meant not all staff had refreshed their learning to deal with emergencies such as a fire.

The design of the service did not align with best practice and legislation. There were gaps in knowledge among the management team and provider in relation to providing care to people living with dementia. Nationally recognised evidence-based guidance was not used when designing and delivering care to them. The building decoration and layout did not support best practice and peoples well-being or independence. This demonstrated a lack of knowledge and a failure to research and access best practice guidance, and dementia friendly environments which can lead to improvements in people’s well-being and independence.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and development. Staff did not work together well to provide safe care that met people’s individual needs.We found that the service did not always have sufficient staffing levels to ensure people’s safety and well-being at all times. For example, we observed that on many occasions there were no staff in the communal areas of the service to consistently monitor and to ensure people’s safety. People were seen sitting for long periods with no interaction from staff.

There had been a number of falls in the service, and we were concerned that if someone rang their call bell (or activated a sensor mat to alert staff they were attempting to walk), staff may not be able to react quickly enough to protect them from further harm. Further adding to staff response times, was the layout of the building which meant staff had multiple areas to cover, and this had not been considered when determining staffing levels.

Staff had not completed all training relevant to their role to ensure they could meet people's care and treatment needs. For example, pressure area care, and dysphagia (swallowing problems). This placed people at risk of harm.

The provider did not assess or manage the risk of the spread of infection in the service. We found some areas of the service to be unclean, including equipment used for moving people. There were towels, flannels, and bars of soap, in shared bathrooms which posed a risk of cross infection. Personal protective equipment (PPE) was not disposed of in the correct waste stream, which meant there was a risk infections could be spread. The Infection prevention and control team visited after our inspection, and following this an action plan was implemented to make the required improvements.

The service did not always make sure that medicines and treatments were safe and met people’s needs. We noted that the morning medicines round took a long time to complete, with the potential for some people not receiving their medicines until later than clinically appropriate and intended by the prescribers.

We identified that systems were not in place so that medicines and their records could be checked to ensure medicines were given to people as prescribed. We found that some medicine charts had not always been accurately and safely transcribed by staff. There were some gaps and inconsistencies in the recorded information available to staff to enable them to manage people’s medicines safely. This related to information about how they had their medicines given to them and for the administration of medicines prescribed for occasional use when required (PRN medicines). Also, some information was available for PRN medicines that were no longer prescribed for occasional use. This could have led to confusion and error.

Records were not completed appropriately to show that medicated skin patches had been safely applied in a way that avoided the risk of irritant skin effects. We found that topical medicines were stored in areas where people could access them and not securely and which could pose a risk to them. In addition, the topical medicines were not being handled by staff in a way that ensured they were only in use within their shelf-lives once opened. For example, dates of expiry had worn off.