Morley Manor Residential 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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

Accidents and incidents were reported by staff and action was taken to mitigate the risk of events happening again. The registered manager demonstrated a good overview of accidents and events and confirmed they would be introducing more detailed audits to evidence themes and trends had been fully reviewed, and any lessons learnt actioned and recorded. There was a clear process for raising concerns and complaints. The registered manager told us about lessons learnt as a result of a recent complaint, and the action they had taken. People had access to professionals, family and friends outside of the service who they could raise concerns about safety with.

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.

Continuity of care was maintained by ensuring staff had access to clear records. People’s needs were assessed before they started using the service. People had hospital passports in place to support safe care and treatment in the event they were admitted to hospital. Staff told us where people needed support with communication they attended appointments with them. People and relatives confirmed there was responsive action if people became unwell. Comments included, “They were straight onto it and always inform me straight away about stuff, the communication is very 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.

There were clear processes in place to manage safeguarding events and the registered manager worked collaboratively with the local authority to support people safely. Staff had received safeguarding training and understood how to recognise and report poor care and abuse. Where people were subject to Deprivation of Liberty safeguards (DoLS) the service had made applications to the local authority and there was clear monitoring in place. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.

People and relatives told us they felt safe. Comments included, “I feel happy, and content here and so do my family about me being here because I am safe.”

The provider worked with people to understand and manage most 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.

Risks to people’s health, safety and wellbeing were assessed and regularly reviewed. Key risks such as fire, falls, skin integrity and nutrition and hydration were assessed and monitored. Staff told us they were kept up to date about any changes in people’s needs through good communication and handovers. We observed care being delivered in line with people’s care plans, which promoted their independence and choice.

Some improvements were required where people presented with distressed and complex behaviours. Whilst care plans were in place to support staff, further detail was required to assess the risks to other people and staff. We did not identify any evidence of impact or harm. We discussed this with the registered manager, and they confirmed they would develop risk plans where required.

Where people required support with moving and handling, there were clear risk assessments in place, and we observed staff following plans of care and using equipment safely.

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 service was tidy, well maintained and safe and there were systems in place to ensure the required health and safety checks were completed. There was a dedicated maintenance worker on site which meant any shortfalls could be addressed promptly. The service had dementia friendly signage to support people to orientate around the home. There was a refurbishment plan in place and evidence of ongoing work and improvements. For example, a new wet room had recently been installed and people’s bedrooms had been upgraded.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Safe staffing levels were in place, and this was confirmed by staff. There was a dependency tool in place to assess how many staff were on duty and this was regularly reviewed. Staff were attentive and responded to people promptly when they needed care and support. Recruitment was managed safely.

Staff had the induction, support and training to be able to carry out their role. Not all staff had received an annual appraisal, but the registered manager told us they were prioritising this.

People and relatives told us there was enough staff to support people safely, comments included, “There are enough staff, I don’t have to wait for anything.”

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.

Processes were in place to ensure people were protected from the risk of infection. The service was clean and tidy, and staff followed good practices to keep people safe. There were stations for personal protective equipment strategically placed around the service. People and relatives complimented the cleanliness of the home.

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.

Medication administration records (MARs) were clear, and people were receiving their medication as prescribed. Topical medication records did not always have clear body maps to indicate where prescribed creams should be applied, and we identified gaps in recording. We also found charts to monitor the rotation of the positioning of patches had not always been completed. However, the shortfalls had been identified by the provider’s medicine audit and action had been taken to address the issues including updated staff competency assessments and working with the pharmacy to ensure clear instructions were available. Where people received high risk medications, care plans were in place.

Staff had received training and had recently updated competency assessments to confirm they were maintaining good practice standards. When administering medication staff wore a red tabard to highlight they should not be disturbed. We observed staff supporting people with their medication safely and kindly.