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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service continues to be in breach of legal regulation in relation to people’s safe care and treatment. We also identified breaches of regulation in relation to safeguarding, staffing and recruitment.

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 have a proactive and positive culture of safety based on openness and honesty. Whilst leaders listened to concerns about safety, they were not always investigated in a timely way. Lessons were not always learnt to continually identify and embed good practice.Leaders and staff did not effectively foster a culture of learning from safety concerns or incidents. As a result, similar concerns continued to arise, and people remained at avoidable risk of harm. The management team were completing lessons learnt documentation to identify what went wrong, but staff were not always following policies or procedures, so they were not effective. For example, staff were not consistently completing incident forms, were not following up on wounds identified on body maps and were not always communicating issues to the management team. We found some incidents had not been reported and therefore no effective analysis could be completed. This identified missed opportunities to learn and improve. Body maps were confusing and did not always offer any updates or any record of improvement or decline.

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 planning documentation was not always up to date and did not always reflect people's current needs and therefore there was a risk of misleading information being passed between services. External professionals told us their recommendations provided to support people’s care were not consistently followed. Systems and processes intended to assess, monitor, and improve safety were often ineffective. As a result, people were exposed to avoidable risk and did not always receive safe or consistent care which met their needs and supported them to achieve better outcomes. One professional said, “There are times where we have advised on preventative treatments after treating a condition and this has not been followed. For example, a patient suffering with [name of condition] was healed but failure to follow advice regarding using a barrier ointment was not followed therefore causing this to breakdown again.” The management team had started to implement a hospital passport to help with the transfer of information.

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 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. There was a safeguarding policy in place and staff received safeguarding training; however, this was not always effectively applied in practice. There were missed opportunities for staff and leaders to learn from safeguarding concerns and review risks to ensure preventative measures were put in place. For example, external professionals informed us of several safeguarding concerns which were related to unwitnessed falls. We found care plans were not always current or gave sufficient detail to mitigate further falls. This placed people at continued risk of falls. The management team were trying to implement new systems and approaches, but staff were lacking in skills and knowledge, and some staff were reluctant to change.

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 Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The management team were unsure which people had an authorised DoLS in place and did not have an oversight about conditions attached to DoLS. The manager was working with the managing authority to gain this information. One person who was known to have a condition attached to their DoLS, had a care plan in place to ensure this was met.  

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 associated with people's care were not always identified to keep people safe. We looked at care plans and found widespread concerns in relation to pressure care, weight loss, and falls. Care plan documentation did not provide clear instructions that were aligned to people’s current needs. For example, one person’s care plan stated they required a sensor mat but did not state where this should be placed and when it should be used. There was no information in this person’s care plan regarding a crash mat which was in use but presented an additional falls risk. Wound care and body maps did not always align creating confusion around wound care and the support people required. There was a lack of reporting wounds. For example, one person had a large bruise to their arm, but this had not been reported and there was no incident form completed. There was a delay in seeking professional advice. Risks in relation to people’s weight were not always adequately addressed. Some people required modified diets and thickened drinks; however, care plans did not always offer enough information regarding these needs. We found daily notes did not always evidence people had received adequate nutrition and hydration to meet their needs.

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. Since our last assessment the management team and provider had been addressing issues raised in a fire audit and risk assessment by an independent company on 2 April 2025. Many actions had been addressed but further work was required and scheduled to take place. Checks were carried out to monitor the safety of domestic systems, including water temperatures, emergency lighting and call bell systems.

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. Staff did not work together well to provide safe care that met people’s individual needs. Since our last assessment the management team had reviewed staff required for each shift and had increased the number of staff to reflect the needs of people. However, staff did not always have the skills and knowledge to carry out their role well, and some staff were reluctant to change. Some mandatory training had taken place, but crucial practical training such as moving and handling had not been carried out in a timely way. Staff competencies had not been completed to ensure moving and handling was carried out safely. The management team told us plans were in place to ensure this training was provided. The manager confirmed that new staff would have a full employment file and receive an induction which will include shadow shifts with experienced staff. We looked at staff recruitment files and found some files lacked application forms, full employment histories and pre-employment documentation and checks. The management team were in the process of reviewing all staff files and identifying issues. The manager had devised a supervision and appraisal schedule to ensure staff received adequate support. This commenced in May 2025. Staff we spoke with confirmed they felt supported by the current manager.

The provider did not always assess or manage the risk of infection. We carried out a tour of the home with the manager and found the home was predominantly clean, but some further refurbishment was required to ensure this could be maintained. We identified some issues in the kitchenette upstairs. The fridge seal was dirty and damaged and kitchen units needed cleaning. Some waste bins throughout the home were not pedal operated, increasing the risk and spread of infection. However, since our last assessment the provider had replaced some floor covering throughout the home to ensure more effective cleaning. Staff had plentiful supplies of cleaning materials, products, and PPE available to them.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Medicines were stored in locked drug trolleys and cupboards within treatment rooms when not in use. Controlled drugs, which have the potential to be misused, had 2 signatures in the register when doses had been given to people. Counts were completed twice daily to ensure the stock level matched the level recorded in the register. Medication administration records (MAR's) had stock tallies completed after each dose, and levels checked on the day were correct. However, it was noted that 1 person had missed doses of antibiotics which had not been picked up on any medicine’s audits. This was to be investigated by the clinical lead. Another person appeared to have been given the incorrect dose of a medicine, so we could not be assured medicines were being given as prescribed. One person had medicines in their tray which were not prescribed on their MAR chart. It was unclear if these had previously been prescribed and could pose a risk of staff administering them without a legal document to accompany it. People that were prescribed as and when required (PRN) medicines, had protocols in place. However, they lacked in depth information, and some people had duplicate protocols which could lead to staff confusion on when to give these appropriately. When staff had administered PRN doses this was recorded on the reverse of the MAR charts, so it was clear when additional doses may be given. Risk assessments were in place for people that were prescribed creams and emollients, as some of these can be flammable. Body maps were in place to show staff where to apply these, but it was noted that they were not always applied as often as intended by the prescriber. This could lead to skin integrity issues. People that were prescribed patches had patch rotation charts in place to ensure these were being applied correctly. Daily checks were completed to ensure they were still intact on the skin. Fridges where medicines were stored had daily temperature checks completed. However, there was no documentation on the sheet to show staff what the temperature range should be and what to do if the temperature went out of this range. It was noted that the temperature went to 9 degrees when the national guidelines show the temperature should be between 2 and 8 degrees. As there were 2 fridges, it was also unclear which monitoring sheets were for which fridge on archived paperwork.