Manor Park Care 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 good. At this assessment the rating has changed to 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 provider was in breach of legal regulations in relation to staffing, safeguarding and safe care and treatment, including infection, prevention and control and the management of medicines.

This service scored 44 (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 based on openness and honesty. 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.

Accidents and incidents were not effectively reviewed or managed by the provider. Where staff had completed reports detailing events such as falls or people presenting with distressed behaviours, forms had been marked as complete without any evidence of management review. We highlighted details of concerning incidents that had occurred the provider was not aware of. There was no evidence of management oversight to identify themes, trends or common risk factors. The provider lacked effective systems to share lessons learned or support staff development following incidents or safety concerns.

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. They did not always make sure there was continuity of care, including when people moved between different services.

We saw some evidence staff supported people with continuity of care and worked with healthcare partners collaboratively. However, shortfalls in documentation meant staff did not always have the required detailed information available to them which could compromise vital information sharing and people’s care and safety.

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 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 share concerns quickly and appropriately.

Processes to safeguard people from abuse or poor care were not embedded or robust. There was no overarching safeguarding log to review any potential themes or trends and a lack of knowledge about how and when to make referrals to the local authority. This meant there were delays in making referrals which meant the provider was not fulfilling their legal requirements, which put people at risk of harm. We also identified events which should have been referred to the local authority. The lack of effective monitoring of events that occurred between people meant we were not assured potential safeguarding events were identified. Not all staff had received up to date safeguarding training.

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.There was a tracker in place which was monitored by the deputy manager.

People told us they felt safe. Comments include, “I like it here. It is safer.”

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.

Risks to people’s health, safety and wellbeing were assessed and recognised best practice tools were used to assist in assessments. However, whilst there was evidence of regular reviews by senior staff, assessments did not always reflect recent events or changes in people’s mental or physical health. For example, 1 person was experiencing an increase in falls and not all the actions that had been identified to mitigate the risk had been addressed.

Environmental risks in relation to the environment were not always regularly reviewed and updated. Risk assessments were not dated or signed and did not show evidence of ongoing action to mitigate risks. For example, the provider had identified installing a grab rail at the top of a steep staircase would reduce potential risks to people, but this had not been actioned.

Personal Emergency Evacuation Plans (PEEPs) were in place, but these were not in the service’s grab bag and were not easily accessible in the event of an emergency. The provider addressed this promptly.

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.

Some areas of the home were not well maintained. Whilst there was a maintenance worker regularly at the service, we identified essential maintenance work was not always carried out promptly which put people at risk of harm. For example, on the first day of our assessment we highlighted there were several light bulbs not working. Records also showed delays in responding to key maintenance concerns such as radiators and call bells not working. Furniture and décor require replacement or repair. When people were smoking outdoors near the entrance hall the smell of cigarette smoke permeated into the communal areas which potentially impacted on other people.

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.

Staff did not receive effective support through a robust training and supervision programme. The training matrix highlighted compliance with mandatory training was poor and there were no detailed plans in place on how this was going to be addressed. This included key relevant training such as mental health and dementia awareness. Staff had not completed learning disability training which is a legal requirement for all registered services. Staff did not receive regular supervision, appraisal or competency led assessments to support and assess their performance.

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. Recruitment was managed safely.

People and relatives reported there was enough staff who knew people well and the consistency and familiarity of the staff team contributed to continuity of care and people’s overall wellbeing.

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.

Whilst we observed staff followed good infection, prevention and control measures to keep people safe there were concerns about the overall cleanliness of the service, including communal areas, equipment and people’s bedrooms. There was also a strong malodour in some areas of the service. Essential hand-washing items were not always available in bathroom areas. Infection, prevention and control audits had not identified the concerns. We referred our concerns to the local authority infection, prevention and control team. The provider responded to our feedback and confirmed they would take action to address the shortfalls we identified.

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.

Medication systems were not robust. Staff told us they only used a handset to check and administer people’s medication and confirmed they did not routinely review people’s individual medication administration records (MARs). This meant they did not have a good overview of people’s medication requirements. The provider told us staff should routinely refer to the MAR on the electronic system but the shortfalls in actual practice had not been identified. Protocols in relation to medication people were prescribed on an ‘as required’ (PRN) basis were in place, but staff did not know how to access them. There was no evidence to support why PRN medication had been administered or follow ups on the result. This meant we were not assured medicines for pain or anxiety were administered consistently or in line with people’s plans of care. However, our checks highlighted stock checks were accurate, and overall people were receiving their medication, including creams, as prescribed.