The Moreton Centre

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 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.

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 listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We reviewed the incident and accident tracker used by the registered manager for monitoring purposes. These were not all used to improve practice or reflected into people’s care plan to improve care delivery. For example, repeated trips/falls, which whilst recorded did not have an ‘after action review’, as to how to minimise further risk and reduce falls. Staff discussions identified that not all falls, trips and near misses were reported. Management agreed to provide further training to improve recording, identify themes and prevent recurrence.

Despite this, we saw evidence of some learning from other incidents, such as discussions in team meetings with staff. During the inspection process, leaders were open and responsive to feedback which demonstrated their commitment to learning.

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.

We were made aware of situation on the first site visit, with a person who was on a ‘decision to assess’ bed, (a ‘decision to assess’ bed is normally for a short period before a permanent placement is found). The person was very unhappy of being so far away from their family and friends which led to disturbances within the service and injury to the person. This developed into a situation which was not safe for people and staff and a decision was made to transfer the person to a hospital near their family and friends. It was not clear from the documentation the reason for a placement so far away from their home or if it had been fully discussed with the person before arriving at the service. The registered manager informed us that they would not be accepting any other people on this pathway.

The management team worked with other health and social care professionals when people moved into the service. People moved on from the service only when they themselves chose to move, sometimes to be closer to loved ones or if the service could no longer meet their needs. Each person had a hospital passport; these documents supported people when they moved between services such as admission to hospital. They contained important information such as people's individual communication needs and medicines.

The registered manager told us they held meetings to discuss people’s changing support needs with the appropriate health professional and where appropriate the hospice team. Staff told us of meetings that took place when there were concerns about needs being met or a person became unhappy or anxious. These meetings involved relatives and all necessary professionals and made sure that the best outcomes were achieved for people.

The provider did not always 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, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We were not fully assured that all accidents and incidents were reported on and followed through to ensure people’s continued well-being. This included those with repeated falls, those at risk from self-neglect and those who lived with increased anxiety. This was because the logs looked at did not all reflect the daily records. Staff and some families also shared that not all incidents/accidents had been reported. Families, however, also told us that they felt their loved ones were treated with kindness and were safe. One visitor told us that staff did not always contact them regarding incidents but would tell them when they visited.

There were a high number of people on 1-1 support and whilst staff were seen to be respectful, there was minimal interaction seen between staff and the people. We also saw that some practices observed were potentially restrictive. For example, the placement of the staff in a chair in the doorway of their bedroom and sitting in front of them whilst they were seated in a chair.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Staff received training in the principles of the MCA and understood their role and responsibility in upholding those principles. The registered manager kept an overview of all DoLS applications and those that are completed, pending and those that were refused. We found that some people’s capacity documentation was not clear and, in some areas, contradictory. This was fully discussed during the feedback session and would be reviewed as a priority.

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.

We observed mixed interactions between people and staff. Whilst some observations showed staff were kind and confident in their approach to people, we also saw, at times, a lack of interaction or poor interactions from staff. We observed an incident when a person became distressed as they required support to the bathroom and we were concerned about how this was dealt with by staff. The registered manager agreed it was not an approved moving and handling or safety intervention. The person’s wellbeing was checked following our discussion, and the appropriate referrals to health professionals were made. The registered manager told us they would also ensure the person’s care plan and risk assessment were reviewed and updated, and refresher training was to be scheduled to take place with the staff team. Staff were also seen using wheelchairs that were not safe or fit for use. On discussion with the registered manager these were removed from use immediately and new wheelchairs ordered. These wheelchairs had not been checked regularly for safety and staff, whilst knowing the brakes were not working and there was a broken arm, still used them to transfer people. Staff told us they had reported the failings, but these had not been acted on. New wheelchairs had now been ordered.

Each person had individual computerised care plans and risk assessments. Care plans and related risk assessments were not all person-centred or reflective of people’s current individual needs. We found references to different names in different areas of the care plan and different ages recorded. Some care plans contained little guidance for staff to follow to provide consistent care delivery to ensure peoples’ health and safety. For example, information in a person’s mobility care plan stated they could no longer use a walking frame and needed to be hoisted but the ‘how to achieve outcomes’ still referred to walking with a walking frame and 1 member of staff. The person’s personal emergency evacuation plan (PEEP) also stated they could walk with staff and walking frame if amenable. There was no information/guidance within the care documentation for the staff regarding the hoist, sling and how to ensure their safety when the person was anxious.

There were concerns identified regarding the records of people’s weights and the lack of oversight from senior staff. There was evidence of recent weight loss which had been recorded but had not been followed up or actions documented to prevent further weight loss. This was fully discussed and the provider assured us that these would all be checked and appropriate action taken if necessary.

Risk assessments whilst updated monthly did not always reflect changes to people’s health and mental well-being. Examples were discussed during the inspection and would be reviewed by the clinical lead against people’s care plans to ensure continuous safe care. For example, one person had mislaid their dentures and was eating a soft diet, however it listed to be offered snacks which included biscuits. It also stated that the person should have 8-10 cups of fluid daily, but we were not assured that these were consistently being recorded accurately. We saw drinks taken away from people that had not been drunk, which were recorded when offered but not adapted to what was drunk, this had the potential to impact on their hydration status negatively.

We found that the personal emergency evacuation plans overview was incorrect and lacked 4 people’s names, which would have caused confusion in an emergency evacuation. We brought this to the attention of the staff at the time of inspection.

Whilst there were shortfalls found, there were also good examples of care planning seen with associated risk assessments. These included, plans for people living with Huntington’s Chorea, schizophrenia and diabetes.

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.

There was evidence that improvements had been made to the décor since the last inspection. However, there were maintenance issues identified that had not been attended to, for example, doors to office areas on units were not able to be closed or secured. We also saw that walls in communal and individual bedrooms were damaged and not repaired in a timely manner. On talking to staff, they identified that they didn’t have a maintenance person on site every day, the maintenance person visited once a week which meant that daily maintenance issues waited for attention.

Premises risk assessments and health and safety assessments were reviewed on an annual basis, which included gas, electrical safety, legionella and fire equipment.

Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuation of the property.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Feedback from staff, people and families was consistent in what they said about staffing. Visitors told us “There are staff seen but they are not free to offer and support when needed” and “Not enough staff, staff can’t really do what they need to, but they try.” Staff told us, “It’s so busy we can’t do our job like we want to, because of the amount of 1-1 we do, we need more staff” and “Just can’t do it all.” Concerns regarding the staffing levels had been received anonymously by the CQC which had, in part, prompted this inspection.

Staff described staffing pressures as having a negative impact on care delivery. One member of staff told us, “We have 6 people on 1-1 and that means there are only 2 staff to deliver care for 8 people, it’s really hard to give the level of care needed” and "The timings of 1-1 have changed and this has upset staff, 6 hours is a long time to be with a person.” 3 of the 4 units had people who required 1-1 support. Another staff member explained that staffing had become increasingly difficult following management changes.

From our observations on the first site visit it was evident that there were not enough staff deployed to meet peoples’ individual needs in respect of support and social care needs. People’s personal care needed attention, for example oral health, shaving and hair. Peoples’ continence needs were not always met in a timely way. Staff told us, “People don’t always want us to assist with all aspects of care but we just don’t always get chance to go back and try again.” From records, people and staff comments we were not assured people were offered showers regularly either in the morning or evening.

The provider had not ensured that staff had received effective support, supervision and development. Staff said, “We do get training both online and face to face, and we support each other, but we are getting different types of residents, younger and with mental health diagnosis, I think more training would help us” and “We do training online but I have not had supervision regularly.” The supervision matrix evidenced that not all staff were receiving regular supervision. Many of staff supervision had been last undertaken by the previous management team and some had gone 6 months without a supervision.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Registered nurses have a unique registration code called a PIN. This tells the provider that they are fit to practice as nurses. Before employment, checks were made to ensure the PIN was current with no restrictions.

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.

The provider had systems and processes in place to support infection prevention and control and reduce the risk of infection spreading within the home. We observed the environment to be adequately clean during our site visits. It was identified that some people’s bedrooms needed cleaning and tidying and this was attended to immediately. Housekeeping staff were visible throughout the inspection and worked hard to keep on top of the cleaning. Relatives also consistently described the home as clean.
Care records demonstrated that infection-related risks had been considered. For example, staff monitored people's skin integrity, physical health and incidence of urine and chest infections and recorded interventions for those at increased risk of infection or skin breakdown. Records also showed that healthcare professionals were involved, when required, to support people's health needs.
However, we identified a small number of environmental oversight issues, including cracked covers on seating and chairs, and unclean moving and handling equipment. While these issues were not directly related to infection control, they highlighted opportunities to strengthen environmental monitoring. Overall, people were protected from the risk of infection through generally effective infection prevention and control arrangements.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff supported and involved people in managing their medicines. Not everyone could share their experiences regarding medication, but one person said, “I get my pills and see a doctor.” One family member we spoke with said, “Staff will inform us of any changes, no concerns at all.”

Medicines were clearly documented in care plans, and staff ensured they accompanied people when moving between healthcare settings. Several people received medicines covertly, which means administering medication without the person’s knowledge or consent by disguising it in food or drink. Records showed that consultations and best-interest meetings had taken place. However, the documentation did not clearly show whether the organisation’s covert administration protocol was being followed or whether staff administering medicines had presumed that people would refuse them and so didn’t offer them. We discussed this with the registered manager, who confirmed that the records would be made clearer.

The management of medicines were very well organised, with minimal extra stock and all medicines no longer required were managed safely and returned as per their pharmacy’s procedures.

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and that they were recorded accurately on the eMAR (eMAR, an electronic medical records software.)

All discrepancies and medicine errors were recorded and investigated and action taken as required. Audits were carried out, and any shortfalls were addressed and used as ‘lessons learnt.’ Protocols for ‘as required’ (PRN) medicines, such as pain relief medicines were in place, not all were informative and person specific, but this is already known by the registered manager. Some people had been prescribed just in case medicines to be used at the end stage of their life.