Maesbrook 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 – 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 Inadequate. 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 regulations in relation to people’s safe care and treatment, safeguarding of service users and governance.

This service scored 34 (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 embed a consistent learning culture, and staff did not always recognise or respond to safety concerns in a proactive way. There were issues across medicines management,care planning, and risk monitoring which had not been addressed despite previous regulatory action.

“People told us about incidents happening between people. However, these were not consistently documented by staff or reviewed by management to identify learning. Three staff members raised concerns about altercations between two people, but no records were found to evidence these incidents, including incident forms or documented follow up actions. This indicated failures in staff recording practices and a lack of effective management oversight to ensure incidents were documented, reviewed, and analysed.”

Family members also raised repeated concerns about delays in care, unanswered call bells, and people being left requiring personal care. We saw no evidence of learning or improvement. One relative said their family member had telephoned them from the home in a distressed way, informing them they required personal care and had been left waiting.

People told us staff were kind, but issues persisted because learning was not embedded. One person said, “What am I supposed to do? I ring and ring the buzzer and still I have to wait.”

The service involved multiple professionals, teams, and services. However, the arrangements did not consistently ensure continuity of care, particularly during transitions between different services.

Systems for coordinating care were not consistently effective.One person feedback on the provider about their experience when transferring from home to the service, the difficulty of dependent on other agencies and trying to chase updates.

People did not always have up‑to‑date risk assessments, including missing eating and drinking risk assessments and incomplete end‑of‑life plans. Families described inconsistent communication around people’s health. One relative told us, staff did not continue observations when asked, and their relative deteriorated and had to be taken to AE.

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. People were not consistently safeguarded from neglect or improper treatment. One relative we spoke with told us their relative been left in distress as they required immediate personal care, they were left in bed awaiting staff. They told us, “[Relative] was very upset, he is a proud man, this has happened on at least 3 occasions.”

The provider could not demonstrate potential risks had been identified, monitored, or addressed in line with expected safeguarding procedures. Some people had unexplained injuries and skin damage. These were not clearly documented to demonstrate the cause had been investigated or that appropriate follow‑up action had been taken. Family members reported delays in obtaining accident records when requested and incomplete explanations.

Concerns were also raised about financial safeguarding, including a £20 toiletries fee and additional £3 charge for water and electricity for hairdressing, with no evidence of agreements or communication with families. We raised a safeguarding concern to the Local authority after our inspection to raise concerns of possible financial abuse. Some people told us they felt safe, but this was not consistent. One relative described the home as, “very happy, for the most part”, whereas others reported distressing experiences.

People had Deprivation of Liberty Safeguards (DoLS) in place where required. The manager had a DoLS matrix in place to monitor the dates of people’s authorisations.

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. The provider did not involve people effectively in managing risks to their health, welfare and safety.

People and families described waiting long periods for help, often leading to anxiety or avoidable accidents. One person said staff told her to sit down whenever she tried to stand, adding, “I need the loo and I ring and ring the buzzer and still I have to wait.”

Some risk assessments were incomplete or missing, including for eating and drinking, wound care, and behavioural monitoring. People’s behavioural needs were not reviewed through Antecedent, Behaviour and Consequence (ABC) charts, meaning staff lacked the information needed to support people safely and identify any trends.

Relatives reported staff did not always respond when concerns were raised. One relative said, “It’s about my relative’s dignity and respect. Communication is lacking and it lets down the team as a whole.”

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.

The environment was not consistently safe or well maintained. The home was dirty in several areas, including carpets, bed bumpers and wheelchairs. There were long standing issues with bathroom repairs, and one person was injured. "One person told us they were injured after banging into a raised toilet seat in an overcrowded bathroom” Fire safety risks were significant, including out dated fire risk assessments, poorly marked exits, and storage in electrical cupboards.

The environment created anxiety for some people. One person said, “I need to feel safe and noise makes me anxious, continual noise from doors at night.”

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 which met people’s individual needs. Staffing levels were inconsistent, and families frequently raised concerns about responsiveness, particularly at night. People reported long waits for call bells to be answered.

People and relatives said agency staff were used frequently, affecting consistency of care. One person said, “They never have enough time to spend with you, always short‑staffed.”

“One relative told us they had concerns following interactions with some recently recruited staff, as communication barriers meant staff did not always demonstrate an understanding of their family member’s needs. One person told us, “Staff struggle to understand [Person] and they are blind and hard of hearing.” We saw no evidence where the provider had supported staff with any language or communication barriers. However, some relatives described staff as caring and attentive, noting they were “very nice” and “kind”, although staffing pressures affected quality.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not maintain consistently clean or hygienic environments. Inspectors observed dirty laundry areas, worn and unclean carpets, and unclean staff facilities. There were concerns about cluttered environments, including mobility equipment stored in communal areas posing hygiene and trip hazards to people and staff. Equipment was found dirty, including bed bumpers and specialised chairs. People commented on poor ventilation and stale air. One relative said, “It is always stuffy in here, I’m always glad to get out into the fresh air after a visit.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Medicines were not always managed safely. Some people required their medicines only when needed. One such medicine helps people to relax, and we saw this had been administered without documented reasons. The daily notes described the person as “happy” or “content” so it was not clear why the medicine was administered. This did not follow the persons care plan.
Care plans lacked detail about when “as needed” medicines should be used or any de‑escalation strategies for staff to use to help calm people.

Some prescribed creams in bedrooms had no opening dates, and staff raised concerns about the feasibility of administering rectal medicine to one person. They told us they had no timely response from nurses or the manager.

Relatives we spoke with expressed confidence in day‑to‑day medicines administration, they told us nurses stayed with people to ensure they took their medicines, though this was not consistent across evidence.