North Court 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.

Maven Healthcare took over the running of North Court from the previous provider in January 2024. Under the previous provider we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

There had been incidents at the home where things had gone wrong which are currently being investigated. Some improvements had been made to safety processes, but we were not assured that the learning from recent events had been fully embedded and built upon.

We identified two people who had bedrails on their beds which had not been risk assessed or documented in their care plan. The rationale for having these bed rails in place was not clear and we could not be assured that staff consistently followed the guidance in the care plan. The manager told us that they would immediately review the use of bedrails across the service.

Relatives told us that communication was good with the management team, and they were kept up to date with changes in their relative’s needs and any incidents which occurred.

The service was working with people and health care partners to make improvements and establish safe systems of care. For example, they had implemented a new electronic recording system. However, there were discrepancies and gaps within the recording and planning documents which meant that people could experience inconsistent care and risk management. One person’s records stated that they should be repositioned 2 hourly but when we checked the repositioning records, we found gaps of significantly more than 2 hours. These shortfalls meant that the systems in place may not be working effectively, and the person was at risk of developing pressure ulcers.

Systems had been strengthened, and efforts made to improve how the service worked with other professionals. An allocated member of staff took responsibility for leading on the GP rounds to ensure better communication. People’s nutritional needs were more clearly recorded to highlight to staff those people who needed additional support at mealtimes.

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. Staff were aware of the importance of escalating concerns and what constitutes abuse.However, not all were aware of local safeguarding protocols but there were posters on display to guide staff.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service was aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

Staff worked with people to identify risks, but risk management was not consistently implemented which meant that people were not always safe.

The provider had started to make improvements as to how risks to people were identified and managed. Daily meetings were held to review people’s needs and any accidents and incidents. Records showed that referrals had been made to other health professionals such as the Speech and Language service and dieticians when deterioration in people’s wellbeing was identified. Regular clinical meetings were held to review clinical issues within the service. Changes included the introduction of new systems for highlighting people’s nutritional needs and the support required. Change was not yet fully embedded, and we identified inconsistencies in recording and care delivery. For example, on the first day of our inspection, we observed a member of staff assisting a person to eat who was sat on the side of the bed. The person was not upright and was slipping down to floor. We intervened as we were concerned that the person was at risk of falling or choking. The member of staff went and got another member of staff, and they repositioned the person in a more upright position. On day two and day three we observed that staff ensured that people were placed in a safe position for eating.

People had good access to drinks around the home. Staff monitored people’s food and fluid where necessary. People told us that they felt safe. One person said “I don’t think they come in the night, but they might do, but late in the evening they pop in and say are you alright. That makes me feel safe, if I need something I know someone is very close by.”

The provider detected and controlled potential risks in the care environment but there were inconsistencies in practice which meant that some areas were missed.

The service was undergoing a major refurbishment and on both floors of the home simultaneously which presented challenges in keeping people safe. Some risks were reduced by areas being temporarily closed off and people moved to other rooms.

Equipment was serviced and essential safety checks were completed on fire safety systems, moving and handling equipment and water temperatures. Personal emergency evacuation plans (PEEPS) outlined the levels of support people required in the event of an emergency. A fire drill had not been completed at night for some time, and a number of wardrobes had not been secured to the wall which could be a hazard to people.

The service was supporting people who were at risk of harm if they left the building unobserved and unaccompanied. Building work was ongoing and some external areas presented hazards. Doors were alarmed and CCTV had recently been fitted to reduce the risks. However, when the alarms sounded staff responded quickly and turned off the alarm, but they did not immediately check whether people had exited the building or the reason for the alarm sounding. The provider said they were due to commence garden works which would mean that the area would be fenced and therefore enclosed.

The provider was receptive and responsive to our findings and took immediate action to address the concerns identified.This included organising for an additional reset button to ensure staff complete an additional check.

The provider made sure that there was enough staff available, but the deployment of staff and checks on staff recruitment and competency required greater oversight.

The management team carried out recruitment checks on staff prior to their appointment but the records, some of which they had inherited from the previous provider were incomplete. The manager provided additional information to demonstrate that disclosure and barring checks and right to work checks had been completed. They told us that they would review all the records to ensure that gaps in employment were explored, and all the required documentation was in place. There were induction processes in place for staff and new checks had been introduced on agency staff to ensure that they had the skills they needed to work in the service.

Competency checks were completed to evidence understanding in key areas, but some gaps were identified for some nursing staff and other senior staff. The provider took immediate action to address the shortfalls and provided us with dates by which the training would be completed by.

A member of care staff spoke positively about the staff training and the opportunities available within the service to take on new roles and responsibility. They told us that the new provider had listened to the issues that they had raised about staffing levels. They told us, “One of the good things about this new company is the increased staffing levels.”

One person told us, “Staff are gentle, but you are aware they are very busy, usually I have 2 staff. Call bell waiting time is acceptable and if there is a wait they do come and say why I am waiting…I do feel safe here.”

A relative told us “There is now new owners and some new staff. It is lovely and they work hard, sometimes not enough staff, I sit in the lounge (ground floor) and then there are no staff as they have had to go off, it is an ongoing thing, you hear a senior person saying I want you to stay in the lounge, but they get called away.”

We observed there were sufficient numbers of staff available and on the day of our visits they worked well together to ensure that people in the communal areas had the support they needed, and call bells were answered promptly. However, the deployment of staff at mealtimes was in need of review to ensure that people were assisted appropriately.

The manager was receptive and responsive to our findings and took immediate action to address the concerns identified.

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 service was clean and there were no malodours, however we did note that some of the toilets were heavily scaled and some of the woodwork was chipped and worn.Descaling records were available and the manager confirmed that improvements would be made as part of the refurbishment, and this was already noted in their internal action plan.

Housekeeping staff told us they were well supported and had access to all the equipment they needed. Staff wore protective personal equipment (PPE) such as gloves and aprons when needed.

The laundry was small which presented challenges in ensuring separate clean and dirty areas. Staff told us that there were plans to create additional shelving to ensure that clean areas were more streamlined.

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.

Records showed people received their medicines as prescribed and that prescribers reviewed people’s medicines. Staff followed safe procedures when giving people their medicines.

Topical medicines were not always being stored securely in areas where people could access them and potentially cause themselves harm. There were some gaps in records for the administration of people’s topical medicines and also records for when people did not receive their medicines.

On our first visit, we found some people were sharing thickeners that had been prescribed individually. Thickeners were not always stored securely but we were assured by the manager that this would be addressed, and we noted improvements on the second day of our inspection.

There were some gaps in the information available for staff to be able to manage people’s medicines safely such as for the administration of medicines prescribed for occasional use when required (PRN medicines). Some risk assessments for people handling some of their own medicines had not recently been reviewed to ensure safety. The manager told us that they would act on the feedback.