Moss Cottage 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

This service scored 56 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had a range of systems in place to provide oversight and ensure lessons were learned when things went wrong. We saw examples of investigations being completed, lessons identified, and learning shared with staff and across the provider's other services. However, at the time of our inspection, these processes were not always operating effectively due to a lack of consistent leadership at home manager and shift leader level. The provider was in the process of recruiting to several key positions and had successfully recruited to some of these roles, although the new staff had not yet commenced in post.

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.

We found some shortcomings in the admission process, including occasions where necessary equipment and care plans were not in place to guide staff in meeting people's care needs. The home supported people to attend healthcare appointments; however, communication was not always effective, and people were not always prepared in time for scheduled appointments, including regular community-based appointments.

Advice and guidance from healthcare professionals were not always incorporated into people's care plans in a timely manner. This included information provided by hospital discharge teams, Speech and Language Therapy (SALT) services, and tissue viability nurses. As a result, it was not clear that staff always had access to the most up-to-date information needed to provide safe and effective care.

The provider did not always work well with systems to understand what being safe meant and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free avoidable harm.

Families were generally positive about the care people received, and most people told us they felt safe living at the home. One relative told us, “During the time in this home there has been massive improvements. My [family member] is safe in here. Carers check their room regularly by popping their heads round the door.”

However, some people raised concerns about how certain staff supported them, stating that their individual needs were not always considered when staff provided support with personal care. We raised these concerns with the provider, who agreed to investigate them further, particularly in relation to how continence care was being delivered.

Where people lacked capacity and were subject to restrictions, mental capacity assessments and best interest decisions were in place, although the quality of these records varied. The provider maintained good oversight of people who were subject to restrictions and had made appropriate applications for Deprivation of Liberty Safeguards (DoLS) authorisations. However, where DoLS authorisations included specific conditions or actions required of the provider, there was limited evidence to demonstrate that these requirements had been fully addressed.

The home worked with the local authority to raise and investigate safeguarding concerns. Most staff had completed safeguarding training, and permanent staff demonstrated an understanding of their responsibilities to protect people from abuse and harm.

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 were not always managed effectively. Risk assessments were in place; however, they were not always accurate or updated in response to changes in people's needs, such as when a person became unwell or experienced a fall. Risk assessments and care plans were not always implemented promptly following admission to the home.

We found examples of conflicting information relating to people's dietary needs, which meant it was not clear that people were consistently receiving the correct diets and fluids. We found evidence that people had been referred to dietitians and SALT services for specialist advice. However, professional guidance was not always clearly incorporated into people's care records. This meant staff may not always have had access to all the information needed. This included guidance from SALT, tissue viability nurses, and targeted intervention to support people at risk of weight loss, such as increased monitoring of weight and food intake and increased snacks and high calorie drinks.

There was limited evidence demonstrating how people, or their families, had been involved in decisions about their care and support. One person told us, “I don't think I was involved in any care planning and there hasn't been any review since I've been in here although my health has changed.” Some people told us they were not always satisfied with the way they were being supported.

The provider responded promptly to concerns and action was taken to address these issues and to ensure all staff, including agency staff, were clear about how people should be supported.

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 a number of areas within the home that required redecoration or additional work to ensure they were safe and suitable for use. This included the outdoor space which, at the time of our visit, was not in a condition that enabled people to use it safely. The provider had an action plan to address these matters.

People did not have all the required equipment they needed. This included access to working call bells and other equipment or adaptations needed to support people safely following admission to the home.

Risk assessments regarding equipment were in place; but did not always accurately reflect people's needs or demonstrate how decisions had been reached. For example, we found occasions where it was unclear how the decision had been made not to use bed rails on both sides of a person's bed.

The provider had appropriate systems in place for the maintenance and servicing of equipment and utilities, including lifting equipment. A new maintenance person had recently commenced in post and was working on improvement of the environment.

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 and development. They did not always work together well to provide safe care that met people’s individual needs.

At the time of our inspection, the home was in the process of recruiting to a number of vacant posts and, as a result, was relying heavily on agency staff in both nursing and care roles. There was limited evidence that agency staff received an induction to ensure they understood the specific needs of people living at the home and the day-to-day operations of the home.

We fed this back to the provider who took action to address these concerns. People, families, and permanent staff all raised concerns about the impact of the high use of agency staff on continuity and consistency of care.

Appropriate recruitment processes were in place to ensure staff could be safely employed.

Feedback regarding staffing levels was mixed, with concerns often linked to the high use of agency staff. One person commented, “The permanent staff are well trained, but the agency staff are not.” People commented on delays in receiving care and told us they would like staff to have more time to spend talking with them, as well as a wider range of activities being available.

A dependency tool was in place to help determine staffing levels, and rotas demonstrated generally consistent staffing numbers. However, there was not always sufficient oversight to ensure the appropriate skill mix, including ensuring a designated fire marshal was on duty. The provider took immediate action to address this and arranged additional fire marshal training for relevant staff.

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 home was generally clean and tidy, and domestic staff worked throughout the day to maintain cleanliness. The provider was aware that some areas required redecoration to support good infection prevention and control practices and had developed an action plan following a visit from the local Infection Prevention and Control Team.

During the inspection, we identified that action was needed to ensure the clinical room was clean, appropriately maintained, and suitable for use. We requested that the provider take immediate action to address these concerns.

Staff were observed using personal protective equipment (PPE) appropriately, and systems were in place to assess staff competency in infection prevention and control, including handwashing audits and observations. Staff had completed relevant training in this area.

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.

Medicines were not managed safely. People did not always have their medicines administered safely or at the right times. We saw that some people could not have all their prescribed medicines for varying periods of time ranging from 1 to 24 days because there was no stock. Manufactures’ guidance was not always followed.

When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the protocols to support their administration were not always detailed enough to ensure medicines were given safely and consistently. Some medicines did not have a supporting protocol, while others contained incorrect information. No records were made to show why these medicines had been administered or if they had been effective.

One person needed to have their medicines given covertly by hiding them in food or drinks. Information from healthcare professionals about how to do this safely was available. However, there was no practical information recorded to guide staff how each medicine should be given.

When people were prescribed thickener to be added to their fluids, to help them swallow the fluids safely, we found the records showed that people’s fluids were not aways thickened to the correct consistency and their thickener was not always stored safely.

One person’s diabetes was not always managed safely. The records showed that their insulin had not been given in accordance with the prescribers’ directions. There was no information recorded as to that person’s safe blood sugar ranges or how to recognise and treat any episodes of hypoglycaemia or hyperglycaemia.

Records about stock levels were not aways accurate and medicines could not always be fully accounted for. Suitable checks of people’s medication needs were not always completed prior to admission.

Most medicines were stored safely. However, the storage of waste medicines and medicines which needed to be stored in a fridge did not follow current guidance for safe storage.

After the inspection we requested some information and an action plan to ensure the concerns were addressed speedily. Information was sent. This helped mitigate the seriousness of the concerns, but we had no evidence due to the timescales that the improvements were embedded or sustained.

We found no evidence that people were harmed at the time of the inspection because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.