Palace House Care Home with Nursing

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to the management of medicines, safeguarding people from harm, incidents and accidents, the management of risks, infection prevention and control and concerns in relation to the environment. As well as ensuring there was a sufficient and knowledgeable staff team.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was some records of incidents and accidents, but these failed to reflect accurately what had occurred, and what appropriate actions had been taken as a result of incidents or accidents. They also failed to demonstrate appropriate referrals to external partners had always been done. Where we saw some people had unexplained injuries the service had failed to seek advice from health professionals to ensure no ill effects had occurred. Records held electronically did not always reflect hand written records which meant it was difficult to always understand what had occurred, the actions taken or their management to reduce any future risks.

Not all staff were able to confirm the appropriate actions to take when unwitnessed injuries had occurred, despite an up-to-date policy being in place. We saw 1 person who had an unexplained injury however, this was not acted on appropriately by the staff member. Other staff fed back that, incidents and accidents were not appropriately acted on. They said, “The same incidents happen repeatedly because nothing is ever followed up” and, “No (accidents and incidents) not (safely managed) at all. Hidden everything under the carpet that’s why (staff) don’t feel safe.” However, other staff members were able to discuss how accidents and incidents should be managed appropriately. Another told us, “When an incident or accident occurs staff complete the forms on the system. The (registered) manager is informed and the next of kin.”

We saw a number of bedrooms had Nobi smart lamps installed in them. Nobi smart lamps areAI-powered ceiling lights designed to detect, prevent, and predict falls. We saw evidence of good information in reviews of the equipment and the monitoring of people. However, there was no reference about the findings from the Nobi smart lamps alerts; any themes, trends or any actions required or planned to reduce any future risks. People and relatives raised no safety concerns.The provider told us they submitted regular reports to professionals involved in the nobi monitoring system. Information in relation to this was provided following our visit to the service.

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.

Care records included information that confirmed health partners were involved in people’s care and reviews. However, where guidance from professionals in relation to some people’s specific needs was seen; this was not always being followed by the staff team. The provider told us of the actions they had taken to address the shortfalls in the records to ensure staff followed guidance from professionals to support people’s individual needs. Not all staff were able to tell us they had been informed of people moving into the service. One staff member said, “You find out when they (people) are already sitting in the lounge or in a bed you didn’t know was occupied.”

Regular visits by the local GP practice were taking place, where people’s health needs were reviewed. Feedback from health partners was that information shared with them as part of these reviews would benefit from more detail to support them and a better understanding by staff of information required to support reviews of people. The service had recently introduced a dedicated staff member who was available to support professionals visiting the service. A professional told us, “I come to the home regularly for me it is nice and friendly. (Dedicated staff member) is superb.”

Relatives told us the service informed them of any changes in people’s needs. One said, “The home (service) always includes me in any changes such as medication or visits to the hospital they always let me know what's going on, I feel I have learnt a lot from them.”
 

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

There was evidence of a number of incidents that required a referral to the local authority safeguarding team to enable an investigation of the concerns and to develop an action plan to reduce any future risks. However, we noted not all referrals had been sent to the local authority in line with both policy and guidance. The service took action to ensure all relevant referrals were submitted to the local authority and notifications sent to the Care Quality Commission. However, we noted one of the investigation reports sent to the local authority incorrectly recorded what had occurred. We saw some records of safeguarding referrals to the local authority, but these did not include detailed information about any actions taken or management of any future risks. This meant people’s risks would not be safely investigated and the development of management plans to reduce future risk and lessons learned would not be accurate.

During our visits to the service, we saw some people had injuries that were unexplained. We witnessed 2 care interventions in the communal area that was unsafe practice. The provider gave assurance that they would take action to ensure people were supported safely and measures were in place to manage safety and safeguarding going forward.

The training matrix identified staff had undertaken safeguarding training. However, not all staff on the duty rota had been included on the training matrix to demonstrate what training they had undertaken. When asked, staff demonstrated some understanding about what to do if they had a safeguarding concern. They told us, “Yes. I would tell my manager if I had any concerns about if people’s needs were not being met” and, “I would report concerns to nurse in charge then (registered) manager and higher and to CQC if no action.” However, others told us they had not completed safeguarding training and fed back that concerns raised with the management team were not appropriately dealt with. One said, “When there are incidents with residents (people who used the service) [staff member] always makes false stories to cover up what really happened.”

No concerns were raised by people or relatives with regard to safeguarding. Comments included, “My [relative] has been here almost [amount of] years it's a lovely home and I know that [person] is safe” and, “My [relative] is as safe as they can be. I spoke to safeguarding (local authority team) last week I told them the same; not because I was concerned it was just because they were here visiting.”

The provider did not 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.

Staff we spoke with did not always understand people’s risks in relation to their individual care needs and how to manage them safely. We also observed the lounge and dining area was left unsupervised on 3 occasions this was despite assurances from the management team that they had confirmed with wider partners that this area would be supervised at all times when occupied by people. This had been addressed by day 3. No concerns were raised by people or relatives in relation to the management of people’s needs.

Individual risk assessments had been included in the care records. However, they had not always been updated regularly. For example, 1 person required a MUST (Malnutrition universal screening tool) was completed and directed that the person required weekly weight, this had not been done. The provider told us they were committed to make improvements and ensured this persons care plan and needs were reviewed without delay.

Weight records were being completed on hand written records and then these were transferred into the electronic care planning system. Whilst some people had records of people’s weights, others had gaps where a weight should have been obtained. One person who was on weekly weights had gaps in their records and had lost weight. Where people had lost weight or staff were unable to obtain a weight, there was no consideration or guidance about alternative ways of obtaining a person’s weight, such as the MUAC tool, (Mid-Upper Arm Circumference isused to estimate weight or nutritional status when standard scales are unavailable) or what to do if someone had lost weight. As a result of our findings a review of all people’s weights and nutritional needs were reassessed by the service and referrals were made to the relevant partner health professionals.

Environmental risk assessments had been completed, including those in relation to the ongoing refurbishment in the service. However, the information in them was not always detailed and followed up to ensure they were up to date or the risk removed.

We reviewed a contingency plan, whilst this was in date and included information to guide staff in the event of an emergency, this was for another service. The provider told us they were working with partners to ensure where people required 1 to 1 staff support, this was in place to ensure individual risks were managed safely. We observed a health professional visiting to undertaken a review of 1 person and the support they required in relation to 1 to 1. A relative told us, “It's reassuring to know that [person] is safe and even though I am disappointed that her one to one was taken from her through no fault of the home (service).” We observed staff undertaking 1 to 1 duties during the visit to the service.

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 a walkaround we identified a number of concerns in relation to the environment. These included wardrobes in some rooms that had not been secured to the wall, items were being stored in an unlocked cupboard in a person’s bathroom that would pose a risk of injury to them and the COSHH cupboard which stored a large amount of chemicals was left open. We also saw a safety gate was left open on the stairs and during a fire alarm staff failed to check a safety gate that opened in the alarm was secured safely. Some of the concerns we had identified had not been picked up on the providers own checks.The provider told us work was ongoing to the flooring in the bedrooms where wardrobes were not secured to the wall.

Some checks had been completed by the provider such as bed rail checks however, these were basic in their content. The provider was developing an action plan to ensure checks on the environment and equipment were detailed to ensure they were safe. External checks such as gas and electrical safety had been undertaken.

There was a PEEPs (personal emergency evacuation plan) file in place, but this required updating as there was a PEEPs in this for 1 person who no longer lived in the service. There was an emergency grab bag and fire safety equipment was in place to use in the event of an emergency requiring evacuation. There was a fire risk assessment which identified some actions were required. The provider confirmed these had been undertaken.

The provider discussed the improvements they had made and further improvements were ongoing. Improvements were seen in some of the bedrooms and bathrooms. Communal areas were homely and nicely decorated. We saw contractors in the home undertaking works during our assessment. No concerns in relation to the environment were raised by relatives.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Relatives told us they were happy with the support provided by the staff team. However, one commented about the recent changes with the staff team and individual staff support for people. Comments included, “My [person] has 1 to 1 and [family member] had to fight to keep it, [person] needs it”, “Staff have gotten to know my [person]” and, “There's been a few changes in staff recently and that has been a bit unnerving for [person], but they've explained that they are trying to get more permanent staff and not use agency as much, so I suppose it will work out better in the long run.”

Staff feedback about the staffing numbers and the training provided. Whilst some told us there was enough staff to meet people’s needs, others raised concerns about the staffing arrangements. Comments included, “Yes, I do (Think there is enough staff). There used to be a lot on 1 to1 but some are not anymore” and, “They have a whole new care team in the home now the seniors are helping to train them up.” However, others said, “We are constantly understaffed and mostly agency who don’t come back” and, “Many of our residents have had 1-1 hours reduced, requiring more regular staff to maintain safety. There have been many staff changes over the past 9 months.” The provider told us they were committed to ensuring sufficient numbers of appropriately skilled staff were recruited to support people appropriately. A new management structure had been recruited to take over from the registered manager who left their role during the assessment.

We checked the duty rotas, dependency tool and daily allocation sheets and saw that whilst these showed the numbers of staff on duty, they did not demonstrate that there was sufficient staff in place to cover all of the care duties in the service for all shifts in the week.We discussed the one-to-one allocation of staff to people where this was required. The provider told us about recent changes in relation to one-to-one staff allocation for people that was beyond their control. They said this was being discussed with the relevant professionals to ensure people received the correct support and staffing allocation to meet their needs.

Staff feedback was mixed in relation to the support provided by the management team. They told us, “[Registered manager] does them, I may have had 1 or 2 supervisions in the last 12 months”, “My last supervision was sometime last year with [Registered manager]” and, “Staff do not feel safe or supported.” Others told us that regular supervision was taking place. We checked the supervision matrix which confirmed not all staff had received a supervision. A number of staff had received and annual appraisal to discuss their goals and achievements but not all. Records had been completed in relation to 6 monthly competency checks however, we saw most of these were dated as completed on the same day, used the same generic format and there was no comments in any of the records as a result of the competency check. A training matrix identified that all staff had undertaken a range of required training. However, we saw not all of the staff names included in the duty rota had been included on the training matrix.

Improvements had been made in relation to staff recruitment. An agency file had been developed which included the names of the agency staff and safety checks. The provider told us they would ensure agency profiles confirmed that they had all received an induction on their first shift in the service.

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 provider took action to address the concerns we found at the assessment.

We saw communal areas were being cleaned regularly with dedicated housekeeping staff in place to undertake these roles. However, not all areas were clean and tidy. These included a stained toilet seat and wheelchair, a cluttered bathroom and dirty linen trolley in the bathroom and dirty laundry left on a shower chair. A linen cupboard was left open, and we saw items such as personal clothing and underwear stored with bed linen, open packets of continence products and personal protective equipment being stored together. All of the trays used by the kitchen staff to support people with their meals were in a poor state of repair. The provider took action to address this.

Whilst cleaning records were seen they were very basic in their content and did not identify which rooms had been cleaned. There was a weekly record to confirm commodes were being cleaned however, this record was blank. The cleaning schedule file that had details of audits and checks in relation to infection prevention and control. Whilst there was some evidence that some checks had been completed a number of records were not being done in line with their schedule or they were blank. These included, the mattress cleaning schedule, the maintenance IPC (infection prevention and control) checklist, the PPE (Personal Protective Equipment) audit and the hand hygiene audit was blank. The provider told us they were introducing an electronic system to ensure all audits and checks were taking place and being monitored regularly.

Cleaning equipment was being stored safely and staff had access to a sluice room which was clean, tidy and locked safely. Information and guidance was on display including an infection prevention and control newsletter, and staff had access to policies and procedures to support safe infection prevention and control. Staff told us they had access to PPE and were not concerned about the cleanliness in the service. We saw staff wearing PPE during our assessment. No concerns were raised by relatives in relation to infection prevention and control.

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.

Systems for ordering, receiving and administering people’s routine medicines were in place so appropriate stocks and information were available.

Information about people’s medicines preferences and allergies were recorded and when people were prescribed medicines to be given ‘when required’ there was usually a plan in place about how to give it. However, some of these plans had not been regularly reviewed and some contained out of date information. One person was prescribed a painkiller that should be given at least 4 hours apart however on occasion this was not always followed.

Medicines were stored securely and temperatures of storage areas were monitored to make sure they were fit for use.

Fluid thickeners used for people at risk of choking were not always accurately and consistently recorded so people were put at unnecessary risk.

Charts used to make sure the site of application of medicines patches was being rotated properly did not always demonstrate this was being carried out correctly. There was a system for recording the application of emollient creams, but staff had on occasion not always signed these records accurately.

Staff had received medicines training and detailed competency assessments and records showed these were up to date.

Medicines audits were carried out regularly, but these had not identified some of the concerns raised during this inspection and required some improvements.