Muscliff 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 subject to avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, and the safeguarding of people from abuse and improper treatment. There were limited assurances about safety and this meant there was an increased risk that people could be harmed.
 

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. Lessons were not learnt to continually identify and embed good practice.

The provider failed to consistently share learning and drive improvements when adverse events occurred. We identified continued inconsistencies with the recording of information, and the provider did not act when alerted to information of concern, which continued to put people at increased risk of reoccurrence of harm.
For example, the manager said, “Staff always review incidents using an electronic platform that encourages the user to confirm action has been taken.” However, we identified records of accidents and incidents were not always complete or accurate, therefore potential themes or actions to drive improvement, had not been identified. The manager told us, “The nurses have flagged these incidents wrong, putting a timeframe on for a review to be completed too soon. Although I am unsure what the timeframe should be, these are all overdue and awaiting manager investigation.”

We immediately escalated this shortfall to the nominated individual, who confirmed action had not always been taken, incidents and accidents had not been discussed and were not known to them. The nominated individual is responsible for supervising the service on behalf of the provider. The nominated individual said, “To address this I will be immediately speaking to the manager as these are sat with them, and they should have already actioned this.”

A health and social care professional told us, “Documentation remains of a variable quality. Some prompts were missed; handover was not always signed by leaders leaving shift and the leaders taking over the next shift. This leads me to query whether the handover was effective, and whether people’s needs known or met.”
 

The service did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The provider failed to ensure people’s transitions into the service were always managed safely. For example, upon a person’s admission to the service, the provider failed to complete a body map to identify if the person had any wounds or areas of concern on their skin that required further assessment or management. Additionally, the provider had been informed the person had experienced a fall. However, they failed to work in line with their falls policy and undertake post-falls monitoring or offer pain relief. We raised out concerns with the nominated individual who said “I expect checks to carry on, absolutely, they should have been monitoring the person when they came back. There is nothing about a return home in the documentation that I can see… This isn't good enough.” The provider was not doing all that was reasonable to protect people from experiencing avoidable harm.

The provider failed to ensure information required to support the continuity of people’s care, was consistently accurate. The provider’s care planning system produced a ‘snapshot’ of care or ‘mini care plan’ outlining people’s care needs. The provider had failed to update these plans to ensure they consistently reflected people’s needs. For example, a person had developed a wound. However, the person’s care plan had not been updated to reflect the wound or how staff should manage this risk, and their ‘mini care plan’ was overdue a planned review so did not contain any information about the wound. This meant the provider could not be assured staff and other services would have access to all the information they required to deliver safe care that met people’s needs.
 

The service failed to work with people to understand and manage risks by thinking holistically. They did not provide care to meet people’s needs that was safe, supportive or enabled people to do the things that mattered to them.

The provider failed to ensure people at risk of choking received modified food and fluids in line with their assessed needs. We observed staff giving people unmodified food and failing to provide support and supervision. Additionally, where a person had experienced a choking incident, the provider had failed to assess this foreseeable risk and implement guidance for staff to help prevent a recurrence. This placed people at increased risk of avoidable harm from choking.

The provider failed to consistently implement guidance for staff in relation to people’s identified health needs. For example, 1 person’s care plan documented they lived with epilepsy. However, the provider had failed to incorporate the person’s epilepsy protocol from the specialist epilepsy nurse. This resulted in staff failing to manage the person’s epilepsy effectively, emergency services attending the service unnecessarily and a safeguarding alert being raised in relation to the incident.

The provider failed to consistently manage risks to people in line with the principles of the MCA. The manager showed us a daily check they had introduced, confirming an independent staff member witnessed personal care for people the service deemed at most risk of abuse. This had been implemented in response to allegations of abuse identified at our previous inspection. However, the check could only be completed after the whole service medicine round, which meant people waited in bed while this was completed. Additionally, the provider had failed to involve people, their appointed representatives or relatives in the decision-making process. Best practice guidance had not been used in the decision-making process.

The provider had failed to drive improvement effectively and in line with their action plan. For example, of 21 care plans the provider had reviewed and updated, we identified inaccuracies and conflicting information in 12 of them, including in relation to people’s food and fluid needs.

The service 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.

The provider could not be assured their fire safety measures would be effective in the event of a fire. For example, the provider had failed to check fire extinguishers in line with their policy. This meant they had failed to identify the fire extinguishers had not been serviced. In response to our concerns, the provider undertook further checks and identified checks were also out of date for the emergency lighting and fire panel. We shared our findings with the local fire service and received assurances from the provider about corrective actions they had taken.

The provider failed to ensure mattresses, used to prevent skin deterioration, were being used in line with the manufacturer’s directions. During this inspection, we identified 5 out of 7 were set incorrectly and not in line with people’s weight. Prior to our inspection, the local authority had reported the same concerns to the provider. The provider’s failure to act meant they could not be assured they were doing all that was reasonable to prevent further skin deterioration.

The provider failed to consistently undertake safety checks of equipment. For example, staff supported people who could not mobilise independently, with wheelchairs. However, when 1 person experienced a fall from a wheelchair, the provider had failed to check the equipment had been safe to use. Additionally, the provider was failing to undertake routine safety checks of equipment in line with their policy. This meant the provider could not be assured equipment was safe to use and without defects.

The providers policy instructed health and safety audits be carried out to ensure safety within the service, including in relation to the environment. These had not been carried out as planned. Therefore, the provider could not be assured the service was safe. This placed people at risk of avoidable harm.

 

The service failed to make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The staff team did not always work together well to provide safe care that met people’s individual needs.

Staff told us there was often not enough time to complete all tasks required of their role, and they had found working with staff unfamiliar with the service challenging. Comments included, “It can be very stressful with the agency staff. Very difficult. The new management team are okay, when we are short staffed then managers help us, with lunch and things.”

In response to feedback we received from staff, the provider told us staffing levels had not been reduced as occupancy at the service decreased and communicated to all staff any additional time worked would be paid. These assurances were echoed in further feedback from staff that, “Things are going better, some days yes, it is quite hard here, because we are scared for everything. But now with the new manager I would say it is better” and, “The managers, they are around all the time. They ask us all the time if we are happy or sad.”

The provider had introduced a range of new observations and competency checks to address shortfalls and improve standards of care within the service. However, these were often partially completed with feedback and action sections left blank, or concerns identified during the observations not followed up on. This meant the process was not consistently effective and did not always support the provider to improve the safety of care and ensure people’s individual needs were met.
 

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.

The provider told us they had introduced an observation to ensure staff were using personal protective equipment (PPE) correctly. However, where these checks had identified non-compliance and risks, corrective actions had not always been taken. This meant the observation tool was not used consistently and effectively. This placed people at increased risk from the avoidable spread of infection.

A health and social care professional fed back, “I have raised lingering odours with the management. It isn’t just unpleasant smelling at times of the day you’d expect there to be smells; say if someone was unwell or it was a personal care round.”

Staff told us they had access to supplies of PPE.
 

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.