Mulgrave House 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. This is the first assessment for this newly registered service. This key question has been rated 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. The provider was in breach of regulation in relation to medicines management.

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. The provider did not always share concerns about safety with staff and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Records showed safety events were not always effectively reported and reflected upon to drive improvements. For example, team meetings for staff were not held regularly. Staff told us even when they did take place the minutes of meetings were not shared. One staff member told us, “I don’t think apart from on handover we get information about incidents.”

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. Systems and processes were not always in place to ensure people were safely admitted to the service. Pre-admission assessments were completed prior to a person moving into the service to ensure their needs could be met. However, this information was not always shared with staff before they moved into the home, this meant staff had limited information. Staff comments included, “Mostly I am finding out on email about a new admission, sometimes the receptionist will share.”

The provider 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. The provider did not always share concerns quickly and appropriately. Some risks to people’s safety were not always identified and/or appropriately reported to partner agencies. For example, errors relating to people’s medicines. This meant information was not always appropriately shared and action taken to mitigate risks and prevent further harm. Staff received safeguarding training and there was a provider policy in place. People told us they felt safe. Comments included, “Yes, it’s quite safe here. I am very well cared for” and “I am safe, I am alright. The carers come and talk to me, and I like that.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. This can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the provider was able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications or/and urgent authorisations in a timely manner.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people’s health and safety were not always robustly assessed, monitored and mitigated. Systems and processes in place were ineffective in ensuring risks to people were consistently and effectively managed. For example, a person had fallen multiple times in a short timeframe. The audit for falls recorded, " No themes" and no further action was taken. Staff told us they had not regularly received updates on accidents and incidents. While staff confirmed that information is shared during handovers, they reported meeting minutes were not provided. Staff also told us that information was not always cascaded to night staff and that certain topics, such as people’s weights, were not routinely reported. Therefore, we could not be assured information was effectively monitored to mitigate risks to people. Care recordswere detailed. Staff told us they read risk assessments. People were supported to mobilise appropriately and staff involved them in the process throughout.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had systems in place to ensure the building was maintained safely, including regular checks and audits. Systems were in place to promote good fire safety. The home décor and furnishings were clean and well maintained. People lived in a homely and comfortable environment and their bedrooms were personalised. One person told us, “I brought my chair from home. I spent a lot of time in the garden in the summer. They put in a cover like a bus shelter especially for me and I sit in there or we can sit outside on the terrace. It’s really good and I have everything I need in my room.”

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 support systems and processes were ineffectively implemented which meant some staff had not participated in supervision sessions and/or an annual appraisal. In addition, some staff had not had their practice competencies checked to ensure they were skilled to complete specific tasks. For example, administering medicines. During the assessment we found significant shortfalls in relation to this and identified a number of concerns. Staff gave mixed feedback regarding staff numbers, and some told us there were times in the day where there were staff shortages and it was more difficult to meet people’s needs. One staff member told us, “It’s busy after teatime, one nurse from 6-8pm and if she needs to have a second authorising person, she has to find one to sign and witness.” In addition, relatives told us, “I think she is safe here. I think they could do with some more staff” and “It’s okay, it depends on the time of day.”

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.Personal protective equipment (PPE) was available for staff to use when required. The service was clean and odour free throughout. Feedback received from people was positive. Comments included, “They come in everyday and dust, and they put a new bottom sheet on my bed every day. It’s clean here” and “They hoover my room; they do keep it clean.” One relative told us, “Cleanliness is not a problem it’s excellent and the laundry is excellent, it’s clean, spotless, they are usually around cleaning and hoovering.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards. Medicines were not always managed safely. The service had systems in place to store, administer and record the use of medications however these were not always followed. The controlled drugs cabinet did not meet the legal requirements for storage. We could not be assured that medicines stored in the fridge were held at a safe temperature because the thermometer did not have a temperature reading at the time of the assessment. In addition, 1 medication was stored on the trolley that should have been refrigerated. Some medicines did not have a dispensing label, and some did not have a date they had been opened. This meant there was a risk out of date medicines may have been administered to people, placing them at risk of harm.

Records showed creams had not been applied safely. The prescribed cream for 1 person, which was to be applied four times daily including to the chest, was not administered as directed. It was neither applied four times per day nor applied to the chest as specified in the instructions. In addition, time critical medications had not been administered at the correct time, this meant people’s medicines were given too soon. Quality assurance processes were ineffective in ensuring medicines concerns were identified and addressed. For example, records showed one person was being administered drops meant for their mouth into their eye. This had not been identified by the provider which meant risks to this person were not being suitably managed.

The provider took immediate action during the assessment and implemented measures to ensure lessons were learned and similar errors were prevented in the future. The provider had failed to identify and address concerns in relation to medicines found during this assessment, placing people at risk of harm.