Malvern 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 good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 investigate and report safety events.

Systems were in place for staff to raise concerns and for these to be addressed by the management team. Lessons learnt from accidents and incidents were documented. However, there was no evidence of trends and patterns identified to mitigate future risks and no records of debriefing after accidents and incidents. Following our feedback, the service responded swiftly to implement changes to address these gaps.

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. However, some improvement was needed.

There was no evidence of a formal pre-admission documents in place for people. The registered manager confirmed they completed pre-admissions assessment, however, did not formally record them. The service had positive relationships with other healthcare agencies involved with people's care, to ensure they received effective care, support and treatment. People and their families were involved in these transitions. People living at the service were appropriately placed and the home could meet their needs.

Systems to record and report safeguarding concerns were in place. However, we found one example where the procedure had not been fully followed. There was no formal record of how lessons learnt from safeguarding events were shared with staff. The service acted promptly and provided evidence the safeguarding concerns we raised had been completed and submitted to the relevant authority. The service submitted evidence of a structed debriefing process they had put in place.

Relatives told us people were safe and well looked after. They expressed confidence in the staff’s ability to meet people’s needs and protect them from harm.

We found staff had received appropriate safeguarding training. Staff were able to clearly explain how to keep people safe and how to recognise potential abuse and the actions they would take if they had concerns.

The service had policies and procedures for the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff understood MCA principles, and applications were submitted where restrictions were in place to ensure decisions were made in people’s best interests.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments in place covering key areas such as physical health, mobility, nutrition and hydration, personal care, mental health, and falls. These assessments were reviewed regularly to ensure they remained accurate and reflected people’s current needs. People had care plans which were detailed and tailored, enabling staff to deliver care that respected people’s preferences and supported their independence.

Relatives told us they were involved in people’s care. Comments included, “When my relative had a medical experience, they phoned us straightaway.”

Staff were knowledgeable about risks and were able to explain how they kept people safe. Comments included, “When displaying behaviour that challenged, I will distract [person] and will speak to [person].”

The provider did not always detect and control potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care.

People did not always live in an environment that was safe and well maintained. For example, some bedrooms were not clean or adequately maintained, and we observed mould on walls in certain areas of the home. Some fire doors were not closing properly, and not all Personal Emergency Evacuation Plans (PEEPs) included room numbers. The service responded swiftly when these concerns was brought to their attention and implemented immediate actions to address the risks.

Systems were in place to check fire safety. Fire alarms were regularly checked, and fire evacuation tests were undertaken. Equipment in the home, for example wheelchairs, were tested in line with current guidance to ensure people could safely use them.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Safe staffing levels were maintained throughout the service. We observed staff were attentive and responded promptly when people required care and support. Staff had completed induction and refresher training, ensuring their skills and knowledge remained up to date. Records showed regular supervisions and appraisals, which provided opportunities for self-reflection and performance review. Recruitment processes were managed safely, with appropriate checks in place before staff commenced employment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The home did not meet hygiene standards. For example, we observed clean towels placed on top of a clinical waste bin, which posed a risk of cross-contamination. Feedback from external partner indicated the home appeared less well presented than expected and would benefit from modernisation.

However, we also observed domestic staff actively cleaning communal areas and bedrooms during the visit, demonstrating efforts to maintain cleanliness. In addition, personal protective equipment stations were in place, ensuring easy access for staff and supporting safe infection control practices.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Some prescribed medicines were not administered in line with national guidance. For example, high-risk medications were not clearly included in care plans for staff to follow. These medications required careful monitoring and management to prevent serious harm. Protocols for medicines which were administered ‘as and when required’ (PRN) were not easily accessible to nursing staff prior to administration. The handheld device used by staff did not display the full protocol, limiting access to guidance when administering medication. Protocols were basic and lack sufficient detail to ensure safe and consistent administration. Medicines administration records (MAR) for thickeners were blank and there was conflicting information.

Creams were applied as prescribed and stored in the clinic room. Controlled Drugs (CD) were managed appropriately. Stock levels were checked and correct.

Staff had received medication training and their competencies assessed to maintain good practice and standards.