Banbury Heights 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

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 Requires Improvement.

At this assessment the rating has remained 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 service was in breach of legal regulation in relation to people’s safe care and treatment, and good governance.

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always report and investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

There was a lack of oversight and monitoring of incidents. Falls and accidents were reported and analysed, however, incidents of distress and behaviours that impacted others were not always reported and investigated. A staff member told us they would report to their line manager or senior leadership team.

Two people’s records evidenced they experienced distress during personal care which impacted staff. Staff had not raised this with managers effectively, and therefore the providers governance systems had not identified or mitigated any risk or investigated the cause of distress. This put people at risk of harm as the risk to the person and staff had not been identified. Another person’s records stated that they experienced distress and caused behaviour that impacted staff and damaged property. Opportunities to learn, support and prevent this from recurring had not been implemented.

People’s relatives told us they knew how to report a safety concern. However, not all relative's felt concerns were dealt with appropriately Comments included “I would speak to the manager and if I have needed to talk to them, they would deal with everything quickly”, “They are very good at letting me know if anything happens”, and, “I have raised concerns about two different situations but I’m not sure if they have dealt with it correctly.”

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.

Relatives told us they felt supported during periods of transitions. One relative told us, on admission to the home, the home “Gave them a welcome pack and one of the staff took [the person] under their wing.” Another person’s relative told us “[Person] were transferred straight from the hospital, and I wasn’t involved in that. [The service] asked me about [the person].”

Staff told us “One day before, the nurse will tell me everything and I will get the room ready. After [the person] [has] arrived, we discuss their likes and dislikes.”

People had hospital passports which included their care plan and needs. These could be accessed quickly in the event of an emergency and were shared with medical professionals to support people to access health services.

This meant people experienced safe continuity of care when moving between different services.

The provider did not always work with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, 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 service did not always safeguard people from harm. We identified concerns in relation to safe medicines management. We raised safeguarding referrals as audits had not identified the issues we found during the inspection. We gave feedback to the provider about the concerns found. They told us they took action to ensure effective systems were in place and would review people’s care. The service consequently made referrals to the local authority.

Staff had up-to-date safeguarding training and access to safeguarding policies and procedures. Staff we spoke to knew how to report concerns. However, due to the concerns we found with staff not escalating concerns with people showing signs of anxiety or distress we could not be assured staff reported all concerns in a timely manner.

The provider had made safeguarding referrals for people who experienced bruising and skin breakdown appropriately and worked with the local authority. Management understood the requirements of the Mental Capacity Act 2005 (MCA) and applied for DOLs (Deprivation of Liberty Safeguards) as necessary.

Records evidenced management and staff worked with people and their representatives to make decisions in people’s best interests.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People and their representatives were involved in care planning and risk management.

Risk assessments for people who communicated an emotion or anxiety and distress were not always in place. Behavioural records in place for 3 people were not analysed to help understand the person's potential triggers. Behavioural tools were not in place to help staff support people to minimise their distress. There were no records of how staff and management responded to incidents of distress, leaving people and staff at risk of harm.

We reviewed 3 people's records who had been noted to be at risk of choking. Risk assessments were not always in place for people who were at risk of choking. A person had been referred to Speech and Language Therapy Team (SALT) for an assessment where it was noted they were at risk of choking. This change had been communicated to the kitchen.

Staff completed appropriate training specific to their roles to reduce the risk to people, including falls, hydration and nutrition, and positive behaviour support.

On the day of inspection, we observed staff to respond to a person’s distress in a caring, calm, manner.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We did not observe any concerns about the equipment or safety of the building.

Staff told us they completed checks of equipment every morning. Maintenance staff completed regular health and safety audits including fire maintenance checks and identified risks, however, the service had identified a fire door did not close. An accompanying risk assessment was not implemented without delay. There was no recorded protocol to mitigate risk to the person during the event of a fire.

Personal Emergency Evacuation Plans (PEEPs) were generic and not individualised to people’s strengths or needs.

PEEPs did not always include information about people’s location within the home, or document the most suitable route to evacuate people using the fire evacuation equipment available. Plans did not reflect how people might react in an emergency and what should happen if they could not be evacuated.

This meant people were at risk of undue harm in the event of an emergency.

People’s relatives told us they felt that their loved ones were safe. Comments included “Everything is secure to get in and out of the building” and “There are always people around to help [person] if needed.”

The home was clean, however in need of some upgrade to décor. The provider had identified the improvements needed and had made progress against an action plan to upgrade bedrooms, replace furniture, and flooring.

Staff received effective support, supervision and development. Staff told us they felt supported by the management team.

The provider had invested in the senior leadership team to improve clinical knowledge at the service. We observed safe recruitment practises, and staff training was up to date. Staff felt there were enough staff at the service.

People’s relatives provided mixed feedback regarding staffing levels. Comments included “They are understaffed most of the time. There are definitely less staff at weekends”, “There are times that it seems fine and other times when it definitely isn’t”, and, “Yes there always seem to be [enough staff] and I visit at the weekends and evenings.” Rotas provided to inspectors evidenced that there were less staff working at the weekends.

People living at the home told us, “Staff answer my call bell when I press the button”, and, “The nurses help me when I need it.”

We observed staff answered call bells without delay, and people were supported in a calm and unhurried way. This meant people received care in a timely manner.

The provider had infection prevention and control policies in place, however measures in place to control the risk of spreading were inconsistent. The provider had an in-date Infection Prevention and Control (IPC) policy which stated “Suitable facilities will be provided through the home,prominently sited”, and that hand gel should be used as an additional hygiene measure.

On the day of our inspection, we observed a lack of prominently sited facilities for staff and visitors to use. Soap dispensers in the nurses’ station were not working however, staff were able to wash their hands in people’s individual bathrooms.

People’s relatives told us that their loved one’s rooms were cleaned regularly, and staff changed bed linen if it was dirty. Staff told us they felt communication had improved around notifications of illnesses. Staff wore personal protective equipment (PPE) and there were safe disposal mechanisms in place. The environment was clean and free from malodours. An Infection Prevention and Control (IPC) Lead carried out IPC audits regularly.

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

Medicines were not always managed safely; we identified several concerns in relation to medicines management.

Medicines that were time-specific were not given in a timely manner, posing a risk of deterioration in symptoms. Medication Administration Record (MAR) charts evidenced people had been given too much medication on several occasions. This had not been identified as part of the service’s regular audits, which meant risks to these people were not being suitably managed.

Where people had when required medicines in place [PRN] protocols did not include clear guidance on dosage limits. In addition, a person’s PRN protocols were not reviewed when there were health concerns, such as being underweight.

We raised this with the provider and made safeguarding referrals to the Local Authority. The provider was responsive and took action to investigate these concerns.

Medication Administration Record [MAR] charts were complete, clear and contemporaneous. Medication was stored appropriately with temperature checks taking place and staff used safe disposal practises for medication that was no longer needed. We observed staff to administer covert medicines and specific medicines appropriately. Medicines when required were locked securely away. Creams applied were documented in Topical Medication Administration Records (TMARs).