Strode Park House

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 service was in breach of legal regulation in relation to people’s safe care and treatment, the way people’s medicines were managed safely and the skills and deployment of staff.

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. 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. There was limited oversight and analysis of accidents and incidents to identify patterns and trends. For example, there had been numerous medicines errors. The deputy manager told us it was the nurses who were making the mistakes, the nurses had been retrained and completed a reflective practice. However, there had been no analysis to identify if there were any underlying issues which could have caused staff to make continuous errors.

Provider audits had identified the management team had not always reviewed incidents within the timeline expected in their quality assurance framework, there was a risk the incident could happen again or be missed, placing people at risk. The deputy manager responsible for reviewing incidents told us they reviewed the quality of the documentation but did not analyse the information.

There was a risk not all incidents would be reported. Some staff told us they did not know how to raise or record incidents when they happened. The recording of incidents took on more significance as the management team were not on site in the evenings, at night or at weekends. There was an increased risk that incidents and learning opportunities would be missed.

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. Before people moved into the service, the management team completed a pre-admission assessment. However, this did not involve going to meet the person to discuss their needs with them to check they could meet the person’s expectations. During the assessment, the management team would speak with hospital staff and would record what was said. But they did not have the opportunity to review the person’s notes to check if the information was accurate or if they needed to ask additional questions.

We reviewed a completed pre-admission assessment, the information recorded was not detailed or person centred. For example, an assessment stated, ‘requires prompting and encouragement as can help but reluctant to partake’, when describing their personal care needs. There was no information about the person’s own choices and preferences. There were no names or contact information about the medical specialists and healthcare professionals who had been involved in the person’s care previously in the community. There was a risk people’s health management would not be managed and maintained when they moved to the service.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated 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 shared concerns quickly and appropriately. The management team understood their responsibility to report safeguarding concerns to the local authority. Staff had received safeguarding training. They could describe the signs of abuse to look for and knew how to report concerns.

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. Potential risks to people’s health and welfare had not always been assessed and there was not always clear guidance for staff to reduce those risks.

Staff were supporting people with complex care needs; risk assessments did not always identify potential risks to people and contained contradictory information. For example, some people were at risk of choking, they required their medicines to be given in a specific way, which increased that risk. There was no guidance for staff about how to give the medicines safely to reduce the risk. Where staff had identified when people were at risk of skin damage, all the risks associated with this had not been recognised and there was a lack of guidance for staff to follow., Where people received oxygen through a nasal canula, there is an increased risk of skin damage around their ears. This risk had not been identified and there was limited guidance for staff to refer to about what signs of skin damage to look for and when to report concerns. People who were at risk of skin damage used pressure relieving mattresses, which are required to be set at the weight of the person, to work effectively. However, we identified mattresses which were set wrongly, for example, double the person’s weight. The manager told us; this had been corrected on our second day on site. We checked and found no change had been made and the mattress continued to be set incorrectly.

There were some people who required bed rails to keep them safe while in bed. However, there is an inherent risk such as bruising from limbs hitting or getting trapped between the bars. The use of bed rail bumpers can reduce this risk. Staff had not assessed these risks and had only used bumpers when people had developed unexplained bruising.

Some people received their nutrition via a tube into their stomach. People who received their nutrition through a feeding tube, were at risk of aspirating or choking if not positioned at 45 degrees

For example, there was an incident recorded where a person had turned blue while lying flat on the shower tray, which was relieved by staff raising the headrest. There was no guidance for staff in place about positioning people on the shower tray.

Where people used equipment, such as an oxygen concentrator machine to provide constant oxygen, this required regular cleaning and maintenance to remain effective. There was no guidance for staff to refer to about when and how this should be completes safely. There was no evidence the maintenance had been completed. Some people required suctioning at times to help prevent aspiration. There was very limited information about when or how to do this, and which staff could perform the process. There was a risk people would not receive suctioning when they needed it by appropriately trained staff.

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. There were maintenance concerns around the service including paint peeling and buckets in some of the corridors to collect water. A relative told us, “The maintenance of it is extraordinary. One corridor always leaks and there’s always towels there on the floor. It’s clean but needs a lot of attention. There are holes in the walls, it needs repainting, wet room also needs to be maintained. The general maintenance is not that great.”

The provider did not make sure there were enough qualified, skilled and experienced staff to meet people’s needs safely. 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. There was no system in operation to determine the number of staff and range of skills required to meet people’s needs and keep them safe. They had not considered the different level of skills and competence required. The manager told us staff rotas were developed by an administrator and there were no systems in operation to plan care staff deployment against the assessed needs of people. The manager was unclear about how many nurses were required on each shift. We reviewed the duty rota for the week of our onsite inspection, the number of nurses ranged between 1 and 4 on duty. Nurses had raised concerns about the availability of clinical support when the clinical lead was not at the service including evenings and weekends. This had not been considered by the provider. Nurses did not have the responsibility to organise or supervise the staff during a shift; this was the responsibility of the co-ordinator. Staff would report any concerns to the co-ordinator for them to action, however, there was a risk the nurses would not be made immediately aware of serious concerns.

The provider did not have an effective system in place to make sure staff received appropriate supervision in their role. Staff had not received supervision every 3 months in accordance with the provider’s policy, this included nurses where only 1 nurse had received a clinical supervision. Although staff competencies had been completed, these had not always been reviewed nor was there evidence staff competency had been effectively assessed to ensure they were competent to complete care tasks, for example, some staff had not their competency for moving and handling reviewed for 5 years. There was no effective system in place to ensure managers and nurses knowledge, and skills were up to date so that they provided safe care.

The provider did not assess or manage the risk of infection effectively. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The provider had an infection control policy in place and a senior manager was the infection control lead. However, there were no effective operating systems in place at the service. The management team told us a deputy manager completed an infection control audit every 6 months, they explained they completed a bit each month., However, it was not clear how any shortfalls would be addressed and checked, there was a risk infection control risks would not be identified quickly.

A lead carer completed spot checks on staff every month around handwashing and assisted the deputy manager with the infection control audit. However, they had not completed any additional training to make sure they understood what to look for in relation to infection prevention and control and were competent in this area.

We observed areas of the service where the floors were stained including some bedrooms and bathrooms. There were areas of the service which needed cleaning and decorating, these concerns had been identified during an environmental walk round in June 25, But no action plan was put in place until after our inspection.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Before this inspection we had identified concerns about the amount of medicines errors being reported by the service. The previous 3 inspections had identified shortfalls in the management of medicines, and this continued at this inspection.

After our last inspection, an electronic system had been introduced to improve medicines management, however this had not been effective.

The electronic system did not meet the needs of the service. Staff had to transcribe all the prescriptions into the system, which did not show the prescription clearly on the tablet device. We found not all prescriptions had been correctly transcribed on to the system, the instructions or name did not match the label on the medicines. People’s prescriptions were displayed on the tablet in a list, when people had a medicine more than once a day which may be a different dose, they had to be listed separately. There was an increased risk people would not receive the correct dose each time as prescribed. For example, there had been 2 occasions where people who had been admitted for respite care, whose medicines had not been put onto the system correctly. Such as, 1 person had not received their medicine to help thin their blood for a week, due to this being missed when the system was being updated.

There was no effective system to monitor stock levels. The electronic system did not have the facility to record when stock was received or adjust the stock number when medicine had been given. Staff completed a paper countdown sheet when they administered a medicine. However, there was no clear 28 day cycle for people’s medicines to follow, people’s medicines stocks were at different stages running out at different points. This increased the risk of people running out of medicines and audits to check if people were receiving their medicines as prescribed were difficult to complete.

Some people were prescribed medicines on a ‘when required’ (PRN) basis, such as analgesia. There were not always clear instructions for staff about when to give these medicines, how often and what to do if it was not effective. There was no process to record the times PRN medicines were given to make sure the required time between doses was maintained.

Some people received their medicines through their feeding tube, this required liquid medicines or tablets to be crushed. However, the instruction to crush tablets was not always on the label and some medicines had coatings as the medicine was slow or modified release. There had been no consideration of how crushing and removing the coating from the tablet would affect how the medicine worked. For example, guidance on the NHS website for levetiracetam, to treat epilepsy, should be swallowed whole and not to be chewed. The medicine is available in other formats to support people who were unable to swallow the tablet, this had not been pursued by staff.

We discussed these concerns with the manager and how the system in place did not support the safe administration of medicines and reduce the risk of errors. They told us they would discuss what action could be taken with the provider.