The Star 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, the ways people’s medicines were managed and staffing. However, immediate and robust action was taken by the provider to address the concerns we identified.

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.

We found that the quality assurance systems and processes in place did not always identify risks to people, for example serious medication errors. When audits did identify concerns there was not always actions taken. For example, an audit found that night checks were not always completed when required but no follow up action was taken. Records also showed that staff had raised concerns regarding staffing levels however, there was a lack of evidence of action taken by the senior team to investigate the concerns. Some people and relatives told us that when they provided feedback they did not always get a response from staff.

However, we saw some evidence that following an incident the service completed an investigation, liaised with the relevant agencies and shared lessons learnt with staff. For example, when someone had a fall, we saw clear information about the action that was taken, the decisions made, and the other people contacted including health professionals and family. Most people told us that they could raise a concern with staff and felt they would be listened to. Leadership responded quickly when issues were identified and took positive action.

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.

We saw evidence the provider made appropriate referrals to partners when people’s needs changed. Records showed that during people’s health reviews staff shared concerns and prompted discussions about appropriate treatment to prevent admission to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. 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 they felt safe and knew who to speak to if they didn’t. Staff could tell us how they would spot signs of abuse and how to report concerns. Records showed that all staff completed appropriate safeguarding training. There was evidence that concerns were shared quickly and appropriately with the relevant professionals. Mental Capacity Act assessments were in place when required and staff understood the importance of gaining consent and people not having unnecessary restrictions. We saw evidence of staff putting additional support in place that reduced the need for medication and hospital treatment.

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.

We found that some risk assessments were not always person centred and contained generic information. There was no evidence that risk assessments were reviewed with the person and risk assessments lacked information about people’s strengths. When people were prescribed ‘as and when required’ medicines, protocols were not always tailored to individual needs, particularly for people with dementia or limited verbal communication.

However, care plans were updated across the service following the feedback and specific high-risk care plans were implemented promptly.
The service demonstrated that they supported people to take positive risks. People did not have unnecessary restrictions in place, and we saw staff supporting someone positively who was distressed.

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.

During one site visit we identified that people had their active pressure relief mattresses incorrectly set which increased the risk of skin damage and discomfort. We also observed someone who was at risk of developing pressure sores sat without a pressure relieving cushion which they had been risk assessed as requiring. However, there was no evidence that any people living at the service at the time of our assessment had developed a pressure sore since moving there.

Moving and handing equipment was available and regularly checked, and there was access to outside space. We observed the environment to be safe, accessible and well maintained. We saw evidence of checks carried out at the premises including gas, electrical and fire safety assessments. Digital systems were password protected with different levels of access depending on staff role.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

The provider did not have systems and procedures which accurately calculated safe staffing levels and the tool used to calculate staffing levels contained inaccurate information about people’s needs.

We received mixed feedback from people and relatives about staffing. Some people and relatives raised concerns around staffing. One person told us, “I do think they need more staff. The atmosphere was happier previously.” One relative told us, “I think the care used to be better. There seems to be less staff now and they all seem rushed off their feet.” During our on-site visits we observed the administrator and activities co-ordinator providing support to people with their daily living activities. Although these staff members had the appropriate training, it meant that they were unable to undertake their work duties because additional care staff were needed.

The provider’s audits identified that staff observations and medication competencies were not being completed in line with their policy. This meant staff performance was not being adequately monitored. However, staff told us they felt supported by the management team and had appropriate training. We saw evidence that safe recruitment checks were carried out.

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.

We found the environment generally clean and tidy with no malodours. Mostly people and staff were happy with cleanliness. Staff confirmed that Personal Protective Equipment (PPE) was always available, and they had Infection prevention and control training.

However, during one site visit we identified that the medicines room required cleaning. Staff reported that cleaning measures had been initiated. During another site visit we saw 1 person’s bedrails bumper was in poor condition. This was immediately replaced.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There was a lack of oversight by the provider and internal audits had not identified the issues we found during inspection.

Medicines were not always given on time or as prescribed. For example, insulin was documented as administered later than prescribed. We saw on some occasions, insulin had been administered inappropriately when people’s blood sugar levels were low without first being corrected, increasing the risk of harm.

We looked at the records of 1 resident who was prescribed paracetamol for pain relief. This was often given too closely and not at the recommended intervals, which increased the risk of harm and reduced the safety of pain management.

Medicines care plans lacked sufficient information for staff to support people with their complex needs. For example, 1 person was on a high risk medicine but the care plan did not state that this required regular monitoring and adequate hydration, to prevent adverse effects. For another resident who was prescribed insulin for diabetes, there was no information about what their blood glucose range should be and when the ‘when required’ insulin should be administered.

When people were prescribed ‘as and when required’ medicines, protocols were not always tailored to individual needs, particularly for people with dementia or limited verbal communication.

Some people had covert medicines plans in place, but these lacked pharmacy guidance or instructions on how medicines should be given safely.

There were systems in place for daily stock counts and temperature monitoring of clinic rooms.
The service had transitioned to an electronic medicines administration system four months before the inspection, but this lacked person-centred information on how people preferred to take their medicines.
Although internal audits were conducted, they did not always identify issues observed during inspection, raising concerns about the effectiveness of governance and oversight processes.

However, no evidence was found that any harm occurred. Immediate and robust action was taken by the provider to address the concerns we identified.