Archived: Lower Bowshaw View 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 people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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 service did not have a proactive and positive culture of safety, based on openness and honesty. They did not always listen to concerns about safety and to ensure events were reported and lessons were not learnt to continually identify and embed good practice.

We identified issues at this inspection that had been picked up at our last inspection in September 2024. For example, concerns were identified in medicines management, staff supervision, risks to people, management of safeguarding concerns and lack of good governance. Theprovider had a poor history of compliance which shows a failure to respond adequately to serious concerns. The provider had failed to embed or sustained a learning culture in the care home. The provider did not learn lessons or maintain improvements to ensure the service improved to good.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Care plans were not up to date, risks were not managed, and advice from healthcare professionals was not always followed. We received concerns from visiting professionals that safe systems were not in place, to ensure people’s needs were met or promoted safety. health care professional told us, "There are a high number of safeguarding concerns, we are continuing to get referrals." Another said, "We are concerned for peoples safety." Visiting professionals also told us requests were not being actioned to ensure people were safe.

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 had not shared concerns quickly and appropriately.

We identified there were a high number of safeguarding concerns the local authority were investigating, which had been identified by health care professionals. We were informed 26 people had a safeguarding raised and these were similar themes. For example, weight management, falls and medication errors. The new management team were working with the professionals to provide required information and documents. However, visiting professionals are continuing to identify new safeguarding concerns and one professional told us, "We are concerned for peoples safety."

People told us they felt safe. One person said, “Oh yes, I am safe here, and they look after me.” Staff told us they received training in safeguarding people and felt they had the skills to recognise and respond to concerns. However, this was not reflected in what we found.

We found people’s rights were not always protected; people’s capacity had not been assessed appropriately to determine if they required a Deprivation of Liberties’ (DoLS) referral. The local authority told us 9 people with cognitive issues had not been referred. We also found best interests’ decisions were not always recorded in people’s plans of care. The electronic care plan system was very basic and did not detail the decision-making process or outcomes.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks were not effectively managed, monitored or reviewed to ensure people’s safety. This was because care plans were not up to date, records were contradictory and guidance for staff to follow was not available.For example, we found one person rushed their food and took large mouthfuls, putting them at risk of choking. The care plan stated they were at low risk and no management of the risk was detailed. This meant nothing was in place to manage the risk of choking.

Risk assessments in the electronic care plan system were very basic, they comprised of, ‘yes’ and, ‘no’ answers in a tick box exercise, they were missing relevant information to ensure staff had up to date information to keep people safe.

Staff did understand people’s risks and they knew people well. However, with agency staff being used, people were at an increased risk due to lack of up-to-date information in care plans and risk assessments.

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.

Checks were carried out to monitor the safety of domestic systems, including water temperatures, emergency lighting and call bell systems. However, some environmental risks were not managed. We found fire exits obscured by chairs and other equipment, outside walkways blocked and not well maintained. Many of these issues had previously been identified and many were quick fixes that had still not been rectified. This showed a failure of the provider to monitor and improve risks to people’s health and safety.

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.

A dependency tool was used, to calculate staffing numbers required. However, it was not clear in documented evidence if the dependencies were correct and if staff numbers met the required hours determined by the tool. We observed staff in communal areas, staff were available to offer care and support, and we did not identify any concerns with staffing numbers on the days of our site visits. One person said, “They [staff] come straight away if I ring the bell, even at nighttime.” The service was relying on agency senior care staff and nurses, which we observed affected the quality of support provided to people. For example, we observed an agency worker concentrated on specific jobs and did not manage or engage with the care staff.

Staff training was not up to date; the manager told us they were working on this to ensure staff attended or completed required training. Staff told us they had to do the online training in their own time and were struggling to get it completed. Staff we spoke with were knowledgeable and understood the importance of training.

The manager confirmed staff supervision was not up to date. However, staff did feel supported by the manager and new deputy manager.

We found communal areas and bedrooms to be predominantly clean. One person said, “The cleaners are always going up and down, it is clean.” However, we found some areas were not well maintained and were unable to be effectively cleaned. For example, damaged floor coverings and lounge chairs. We also found some issues which required attention, such as, continence pads not labelled in open bags in communal toilets and bathrooms, a prescribed cream found in one bathroom, paper towels and wipes on top of toilet cisterns and equipment stores cluttered which meant they were unable to be effectively cleaned.

Staff were aware of correct policies and procedures for infection control. However, we found soap dispensers which were empty, and PPE stores for aprons and gloves required replenishing. Staff did not have easy accessibility PPE to ensure it was used appropriately, to prevent the spread of infection.

Medicines were not safely managed. Medicines trolleys and fridges were not always stored securely in an appropriate room. Temperature monitoring of these rooms and fridges was not documented daily as per the home’s policy. This issue had not been identified by management or staff when completing monthly audits. The audits had noted discrepancies in medicine stock balances however, no action had been taken as issues were still identified. For example, one person was prescribed a medicine to be taken twice a day, for a full months cycle the person only received it once a day, this could have a negative impact on their health and wellbeing. On the day of our inspection, previous stock levels had not been carried forward to the new cycle and we found that stocks of medicines were disorganised.

Controlled drug stock levels were not checked regularly. However, stocks levels checked on the day of inspection were found to be correct.

Where people were prescribed ‘as and when needed’ (PRN) medicines, up to date protocols were not always in place, to show staff when to give these medicines appropriately.

Where people received medicines via a patch, charts were in place for staff to document patches were still intact on the skin. However, these were not always signed daily by staff, so we could not be sure they were still in place.

Creams were not stored securely, and body maps were not in place to show staff where to apply these. Some pharmacy labels attached to topical creams had directions of where to apply these on the body, but some did not have clear instructions. Therefore, staff did not always have guidance on how and when to apply these appropriately.