St Margarets 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 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.

Risks in relation to people’s care needs and the safety of the environment had not been effectively managed or mitigated. The service had not learned from incidents and this meant people were exposed to ongoing risk.

People were protected from abuse and staff understood local safeguarding arrangements.

Staffing levels were sufficient but staff were not always effectively deployed. Recruitment processes were not entirely robust.

The service did not always make sure that medicines and treatments were safe and met people’s needs and preferences.

The service was in breach of the legal regulations in relation to, the need for consent, and safe care and treatment.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incidents and accidents that occurred where not consistently used as opportunities for learning and improvement. For example, one person had experienced 3 choking events in a year, their care plan had not been reviewed and guidance had not been provided for staff on how this risk should be managed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had systems to ensure people’s needs were recognised and understood during transfers of care or in the event a hospital admission was necessary. The service engaged positively with partners and proactively shared information to help ensure support was provided consistently.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were protected from abuse. Staff and manager understood local safeguarding arrangements and information on how to report any safeguarding concerns was available to people, visitors and staff. Staff were confident any safety concern they reported would be acted upon by the registered manager. They told us, “I feel the residents are safe” and “People are very safe. I think so, most families are happy”.

Managers and staff did not have a complete understanding of the requirements of the Mental Capacity Act (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Systems for assessing people’s capacity to make decisions were not effective and it was unclear how people and their relatives had been involved in best interest decision making.

The service did not hold cash on people’s behalf. People were invoiced for any purchases made. This helped ensure people were protected from the risk of financial abuse.

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.

The provider did not have effective systems to assess and mitigate risks to people’s health and well-being. For example, one person had experienced 3 choking incidents in a year. Their care plan and risk assessment had not been updated following these incidents. In addition, information known to the registered manager and clinical staff about how this person’s behaviour contributed to their choking risk had not been documented. Staff had not been provided with clear guidance on how to support this person to eat safely.

Staff were also not provided with guidance on how risks associated with people’s health conditions; including Parkinson’s disease and Diabetes should be managed. Where blood sugar levels were being monitored, information had not been provided on what levels were considered abnormal, or how staff should respond.

No one living in the service had a pressure injury at the time of our inspection and the provider’s director told us, “I don’t think we have any pressure areas or things like that.” However, the service’s systems for managing risks to people’s skin integrity were ineffective. We identified that 4 people were sleeping on air mattresses that were incorrectly set, exposing them to unnecessary risk.

Some people were known to become upset or anxious and to act in ways that put themselves and others at risk. These risks had not been fully assessed and staff had not been provided with clear guidance on how they should support people when upset.

A person was in receipt of oxygen therapy, no specific risk assessment had been completed, and the person was being supported with oil based emollient creams contrary to fire safety best practice.

The provider 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.

Significant risks in the environment of St Margarets Nursing Home had not been recognised and mitigated. Safety features including; window restrictors on first floor windows and radiator covers in communal spaces and within people’s bedrooms were absent. No risk assessment had been completed, identifying how risks had been mitigated in the absence of these safety devices. This meant people were unnecessarily exposed to significant risk of harm. The commission took action to ensure these risks were promptly mitigated.

In addition, flooring on the first floor of the service was heavily worn and in one area represented a trip hazard to people while moving around the service. This issue had not been identified or addressed prior to the inspection. Following feedback at the end of the first day of the inspection, the provider commissioned works to replace the flooring on the first floor and these works were underway during the second day of our inspection.

The service’s utilities, firefighting and detection equipment had been regularly tested and serviced by appropriately skilled contractors. Lifting equipment had recently been serviced.

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.

The service employed sufficient numbers of staff to meet people's needs. Rotas showed that planned staffing levels were routinely achieved and staff told us, “We usually have enough staff”, “I think there are enough staff. We are quite organised and try to get everything done” and “There is always a nurse on duty, there’s got to be.” However, staff were not always deployed effectively to enable prompt responses to people’s requests for support. These issues are detailed more fully in the responsive section of this report.

There were processes for the induction of new staff members and for refreshing staff training to ensure they had the skills necessary to meet people’s needs. Staff told us, “The induction was great” and “We do get [training packages] and they are brilliant. I take mine home and do them. I am going to be doing my NVQ 3 and have done care certificate previously.”

The service’s recruitment practices were not sufficiently robust. Evidence was available to demonstrate Disclosure and Barring Service checks had been completed for all staff employed. However, records showed employment histories had not been fully explored via application forms or interviews and references had not been consistently sought from previous employers in the care sector. This meant the provider did not have access to all necessary information to ensure people’s safety while making recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and infection control risks were appropriately mitigated. Personal protective equipment was available to staff when required and hand washing gel was available throughout the service.

People and their relatives were consistently complimentary of the cleanliness of the service and told us, “The home is extremely clean and tidy”.

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.

People’s medicines were recorded on medicines administration charts. These showed that generally people received their medicines as prescribed. However, records for application of creams and topical preparations were not always recorded as being used as frequently as prescribed. Allergies were recorded on these charts, and also on separate cover sheets, care plans and handover sheets. However, these records did not always match each other.

When medicines were prescribed ‘when required’ staff could describe when they would need to be given and were knowledgeable about people’s needs. However, there were no protocols or guidance in people’s care plans about these medicines and when they should be given.

Medicines care plans lacked details, and risk assessments were not in place for some medicines including blood thinning medication, storage and use of oxygen and flammable topical preparations, to show that people’s individual risks had been considered.

Nurses had updated medicines training, but there was no formal system for recording if their competencies were checked to make sure they gave medicines safely. Medicines policies did not cover all areas of medicines management. For example, there was no policy or system for reporting any medicines errors or incidents so that learning and improvements could be made.

Monthly medicines audits were completed but these focused on stocks levels and medicines charts. There were no recorded audits of other aspects of medicines management, such as storage, policies, care plans or risk assessments.