Palmerston House Care 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.

We identified breaches of the legal regulations. The provider failed to deliver care that met people’s needs, reflected their preferences, there were also concerns about safe care and treatment, medicines management, and infection prevention and control.

This service scored 50 (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. Lessons were not always learnt to continually identify and embed good practice.

Whilst the registered manager did investigate safety concerns and events there was not always a practice of putting measures in place to mitigate concerns identified. For example, staff identified a person who could be at risk of scalds in bed from hot drinks because of having a cluttered overbed table. The clutter reduced the available safe space to place the drink, increasing the likelihood of it being knocked over or spilled onto the person. Whilst this risk was identified and escalated appropriately, the care plan and risk assessment had not been updated to mitigate this risks and guide staff to work safely.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was manage.

There was evidence of working with local health services such as district nurses and local GP’s where there were visits and reviews conducted on site weekly to manage the changing needs of people who used the service.

There was positive interaction noted when assessing potential people being admitted into the service. There was positive and valuable information captured that assisted in identifying needs, preferences and wishes of those being considered for admission. This assisted in highlighting areas of risk. However, not all information was acted on, implemented and risks mitigated once identified through appropriate care planning and risk assessment.

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 told us that they felt safe living at the service. Feedback from people and relatives included, “It has been good, communication is good any problems you can talk to them”, “Yes, I am safe here, nice staff who pop their head around the door they chat”, and “They look after [family member] well, staff are very caring gentle – [family member] feelings come first.

Systems were in place to record any safeguarding concerns. The provider demonstrated good communication with the local authority, for example safeguarding concerns were raised in an appropriate manner and timescales, there was evidence of collaborative working. Information was shared appropriately with social workers and other professionals to address any concerns that arose.

Staff were able to describe signs of potential abuse and were confident these would be dealt with appropriately by the management team. Staff had received training in safeguarding and understood their responsibility to protect people from harm. However, at the time of our assessment two staff members had expired safeguarding training. Staff told us they felt comfortable to raise concerns.

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.

Our inspection team reviewed a sample of care plans and risk assessments, we found where people had these in place they were detailed, and person centred. However, this was not consistent for everyone, and not all people had an assessment of need completed or care and support plans. For example, we found one person had multiple care and support needs but did not have care plans to meet those needs for personal care, skin integrity, and mobility, despite being assessed as needing to be cared for in bed. This placed them at risk of not receiving appropriate care and support that met their needs and reflected their preferences.

We were not assured people at risk of developing pressure injuries had been repositioned in-line with their assessed need, as records did not consistently demonstrate that required repositioning had taken place. There were shortfalls in repositioning records, and we found no evidence that they were being carried out in line with people’s needs. This meant people were placed at risk of experiencing skin damage. We spoke to a visiting healthcare professional, who confirmed there was a history of pressure ulcers being acquired at this service due to inappropriate repositioning.

Risks to people were not always effectively monitored, some people were placed at unnecessary risk of falls due to a lack of guidance in care and support plans. For example, one person was assessed at being at high risk of falls and had an assessment in place for bed rails no further information was recorded. We found bed rails for this person had been removed, and the reasons for this had not been updated or reflected in the person’s risk assessment. Another person was assessed as needing support from two staff members when mobilising, however, there was no mobility care plan in place or risk assessments to support the person safely.

We found the provider had not supplied all the equipment needed to support one person safely whilst they were in bed. Whilst this person was at risks of falls from their bed the provider had not found a solution to manage these risks effectively to maintain their comfort and dignity. Following the inspection the provider informed us they had taken action to address this concern.

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.

Environmental risks were not always recognised or addressed, which placed people at avoidable risk. We found shortfalls in the management of risks related to the care home environment. There was an absence of appropriate measures to ensure people, staff and visitors accessing the building were appropriately protected from environmental risks.

There were wires and other trip hazards noted in four bedrooms and communal areas, this is significant due to the number of people present who were at risk of falls.

We found that PEEPs (personal emergency evacuation plan) had not been fully completed for all people, when asked the registered manager advised us that a recent fire inspection had advised them that a PEEP had to be completed by a relevant professional and that they were querying this. They had not ensured risk assessments or safe processes were in place during the interim, resulting in potential harm to people who had no safety measures in place. We observed a sluice room left unlocked and accessible by vulnerable people on both our site visits. This put people at potential risk as the rooms had Control of Substances Hazardous to Health (COSHH) products accessible as well as IPC (Infection prevention and control) considerations. Due to the experience of some people with dementia in the home there was a risk to their health if they had gained access to COSHH products, because of the risk of ingesting or interacting with hazardous substances. This could lead to avoidable harm such as poisoning, chemical burns and eye injuries.

The provider did not always make sure that staff were supported to complete their mandatory training. They did not always make sure staff received effective development. They did not always work together well to provide safe care that met people’s individual needs.

The training matrix showed that some training had expired across 6 staff members, training that had been deemed mandatory by the provider including dementia care, fire safety and first aid.

The provider’s governance systems and processes meant staff had not always been safely recruited, because there were gaps in employment history, references were not always obtained and when they were they were not verified. This did not follow the provider’s own policies and procedures to ensure recruitment checks and records were accurate and contemporaneous to confirm staff were safe and suitable for employment.

There were sufficient care staff rostered regularly to meet the needs of people, however feedback obtained was mixed, a family member told our inspection team, “The resident staff ratio is good here.” When describing personal care and the wait for it another family member told the inspection team, “The care could be improved – [family member] can be sitting and waiting time for 10 minutes – [family member] needs 2 staff and often there is a wait, leading them to be wet.” A person told us in relation to the call bell, “The waiting is ok.” Another person described the night shift, “The night wait is ok, they (staff) always say sorry we were doing someone else.” One staff member told us, “I think the staffing levels are ok, there can be times we are short staffed if people call in sick. We used to use agency, especially during covid, we haven't had to for a long term.”

We looked at staff supervisions and there was evidence of staff supervisions happening. On reviewing supervision records these appeared to be task orientated and focused on the provider’s set goals and benchmarks. Supervisions did not consistently support staff development needs. This limited opportunities for staff to reflect on their practice, identify areas for growth, and receive guidance that would help them develop their skills and confidence in their roles. This was an opportunity that was missed for leaders to embed positive culture to the wider staff team.

The provider did not assess or manage the risk of infection.

The provider did not maintain adequate cleanliness across the service, resulting in infection risks and poor hygienic condition of people’s rooms. The inspection team observed that sinks in all communal bathrooms, drains and overflows were dirty and did not look like it had been recently cleaned and walls in the communal bathrooms were stained with soap that had run down from dispensers causing the wall to blister and peel. In one person’s bedroom there was a used urine bottle left on the floor and flooring around the toilet was stained. There was one cleaner/housekeeper employed by the service, they were not on shift during our first site visit. The feedback we received from people included, “[Staff member] does some of the cleaning but [Staff member] won’t hoover every day, [Staff member] wipes the door handle, the light switch, edge of the tv, sometimes the wardrobe, sometimes my table but only wipes half of it, we need a proper cleaner, [Staff member] does hoover but not regularly and never moves anything on the floor.” This impacted on people’s wellbeing this also led to poor satisfaction on how people’s rooms were maintained.

The provider had systems and processes in place to manage medicines, these were not fully robust, and some improvements were identified.

Medicines records were not always detailed or consistently completed, meaning staff did not always have the information needed to administer medicines safely. Medicines reporting did not always follow the provider’s own policies and as a result medicine audits were not effective in identifying shortfalls.

Medicines audits were in place to check stocks, administration and PRN administration Medicines stock counts were conducted with the inspection team these did not tally and there was not sufficient information in the audits completed to explain the gaps in MAR (medicine administration records) charts and or discrepancies in recorded administration records.

We found audits in place were not robust in identifying and mitigating risks.

Medicines were administered and people using the service said they were satisfied with staff support when they needed their medicines. One person told the us, “Medication is always on time, they always stay, if in pain I talk to the carers and they pass it up the line, I do get pain killers.”