Moorhead Rest Home

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• 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 was in breach of legal regulations in relation to providing safe care and treatment, premises and equipment, safe staffing levels and safe recruitment processes.

This service scored 38 (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 listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. The recording of accidents and incidents was not always completed and post falls checks were not taking place. There was a lack of oversight in analysing trends and themes which meant we couldn’t be assured measures were in place to monitor or reduce future risks. The manager told us learning outcomes were documented and shared through team briefings and supervision, however, we saw no evidence of this.

The lift was broken during our site visit, and we found one person alone in their bedroom who had spilt a cup of fluid on themselves. Concerns were raised at the last assessment about the monitoring of people who were alone in their bedrooms when the lift was broken. While the people and staff we spoke with expressed they felt risks were managed, our assessment found elements of risk management did not meet the expected standards.

The service worked with people to ensure there was continuity of care, including when people moved between different services. Relatives told us the transition process for people moving into the service was smooth and people had settled into the service well. One relative said, “It was difficult at first, but [person] has settled in now, the home is a bit dated, but they’re happy there and the staff are lovely.” The manager told us, “We do initial assessments for physical, emotional, mental health and social needs.” Staff said, “We get told about new admissions at handovers and we read the pre-admission forms to get to know people’s needs.”

Hospital packs with important information in were printed and sent into hospital with the person to ensure hospital staff knew people’s needs.

The service 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. We witnessed safety concerns during our assessment. Doors leading to outdoor areas were not always secured which meant people were at risk of walking outside alone with no staff observation into an area that was cluttered and unsafe. We observed a person to be distressed during our site visit and a staff member walked away with their fingers in their ears.

While the people and relatives we spoke with expressed they felt people were safe, our assessment found elements of safeguarding did not meet the expected standards. Staff were not aware of what the term Deprivation of Liberty Safegaurds (DoLS) meant and could not confidently say who had a DoLS in place and what that meant for the person. A high number of staff had not completed training in this area or their training course had expired. We saw little evidence of safeguarding outcomes or lessons learnt processes.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were not completed effectively. Skin care risk assessments were calculated incorrectly meaning people were at higher risk of skin breakdown than the assessment evidenced. This meant people were not receiving the appropriate care and treatment to manage this risk. Other risk assessments contradicted each other. For example, one person’s risk assessment stated they required glasses, but another document stated they didn’t. This meant staff may not be aware of the person’s visual requirements which could lead to the risk of falls. One person was observed on several occasions to be walking alone in the outdoor area and on one occasion with only one shoe on. The person’s care plan evidenced the need for this person to be observed to ensure they were safe and well, this was not the case.

While the people and relatives we spoke with expressed they felt risks were managed well, our assessment found elements of risk management did not meet the expected standards. People’s distressed behaviours were not always manged well. Staff told us a person displayed distressed behaviours daily, however, this was not documented. This meant there was no analysis of what may prompt distressed behaviours and no audit of how this could be prevented or better managed to support the person.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The environment was not always safe. The doors leading to outside were unlocked, despite this being raised at the last assessment as being a risk to people. This meant people could be walking alone in the outdoor area which posed a risk to people due to clutter being present including mattresses, broken chairs and a broken sink. The cellar was cluttered and contained continence pads on the floor, out of date food and out of date dressing packs.

Fire risks were not always managed well. Where concerns were found, there was no evidence of what action had been taken to rectify these concerns. PEEPS (Personal Emergency Evacuation Plans) were in paper format and electronic. However, the paper copies contradicted the electronic copy which meant there could be confusion on how to safely evacuate people. There was no evidence of fire drills or worst-case scenario drills taking place, despite this being highlighted by the fire service and mentioned in the service’s fire policy. The fire policy also mentioned the need for a fire marshal to be appointed each day. However, this was not the case and staff confirmed they did not know about fire marshals and had not attended a fire drill. One staff member said, “There are no fire drills and no fire marshals, we should really have this shouldn’t we?” A high number of staff had not completed fire safety training.

While the people and relatives we spoke with expressed they felt the environment was safe, our assessment found elements of safety did not meet the expected standards. PAT (Portable Appliance Testing) had expired as had the Gas Safety Certificate. We saw no evidence of wheelchair or bed checks taking place to ensure their safety. The flooring in the lift was unsafe and could pose as a trip hazard. Some carpets and floors were ripped, again this could pose as a trip hazard.

The service did not 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 work together well to provide safe care that met people’s individual needs. Most staff we spoke to felt there was not enough staff. One staff member said, “There is not enough staff on days. When it is the weekend there is no manager or deputy. When I am giving out medicines, and staff need to tend to someone who needs 2 staff, there is no cover on the floor.” Another staff member said, “We are very short staffed of an evening, after 8pm there are only 2 staff on. If someone is agitated or distressed there aren’t enough of us to reassure them.”

We reviewed the duty rota and found most evenings after 8pm there were only 2 members of staff on duty. However, we reviewed 2 people’s care plans that stated in times of distress 3 staff may be required. This meant people were at risk of harm due to low staffing levels.

Staff recruitment processes were not robust and although the records for the staff we looked at were recruited prior to this provider taking over the service, no risk assessments, audits or checks were put in place to ensure staff were safe to work in this environment. The importance of auditing recruitment files was discussed at the last assessment. We requested the Managers staff recruitment file numerous times before we received this. When we did receive this the interview notes had no date and we saw no evidence of DBS (Disclosure and Barring Service) checks.

The supervision policy states staff will have 4 supervisions a year but we saw no evidence to suggest staff were having regular supervisions. The training matrix evidenced large gaps in staff knowledge. Not all staff were listed on the training matrix and many courses were either not completed or had expired.

People and relatives felt there was enough staff. One relative said, “There seems to be plenty of staff, but I think they have cut back. There is always staff there when we come in and they make sure [person] has everything they need.” While the people and relatives we spoke with expressed they felt staffing levels were safe, our assessment found elements of staffing did not meet the expected standards.

The service 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. Unpleasant odours were identified during our site visits in some bedrooms and corridors. We observed stained and damaged carpets and flooring which would prevent effective infection prevention and control practices. One bedroom had black staining around the window and another bedroom had damp patches on the ceiling. Communal bathrooms had rusty grab bars and a rusty bath lever was identified. We were told conflicting information about the use of the cellar. Some staff advised this was used as a sluice while other staff said it wasn’t. The cellar was cluttered with various items and the flooring was damaged. During our 3rd site visit we observed clean laundry in baskets on the floor of the cellar which would suggest it was being used as a sluice or for storage of clean laundry.

People told us the service was clean and tidy. One person said, “They (staff) clean my room every day and the lounge and dining room are kept clean and tidy.” PPE (Personal Protective Equipment) was available and we witnessed staff wearing this as appropriate.

Staff told us the service was kept clean, however, some concerns were raised. One staff member said, “The home is clean but there have been cutbacks. For example, the dishwasher has been broken for ages, so we have to wash everything by hand which takes time off the floor.” The IPC policy named the IPC champion as a staff member who no longer works for the service.

Medicines were not always managed safely. Since the last assessment we saw that the service had made improvements to how medicines were stored and managed. Staff were signing medicine charts when medicines were administered, and storage of creams had improved. However, there were still issues with the management of medicines that needed to be addressed. Some records lacked the detail required to administer medicines properly. For example, there was no indication of which eye to administer drops for a person with eye drops prescribed. When required medicine records did not explain how or when someone may require their medicine, which meant they were at risk of not receiving the medicine they needed. Where people were prescribed paraffin-based creams and emollients, there were no risk assessments in place to assess how people would remain safe from the risk of fire. Staff who applied the creams were unaware the creams were flammable and had not received training to support them.

Records showed there were not enough trained staff to administer medicines. There were only five staff trained, which meant that some shifts did not have medicines trained staff on duty. Staff told us they started early and stayed late to make sure medicines were given at the right time. In addition, only one of the five staff members had an up-to-date competency assessment record. Care plan records showed that non medicine trained staff had applied medicated creams and they also showed they were not always applied in the way they were prescribed.