Shottendane 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 registeredprovider/service. This key question has been ratedrequires 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 topeople’s safe care and treatment.

This service scored 59 (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.

Staff were knowledgeable about the systems used for reporting and recording incidents when something went wrong. Incident forms were completed, and daily notes were also used to document any concerns regarding people’s care and wellbeing. Staff explained that concerns or issues were shared during handovers so everyone was aware and could escalate them when necessary.

One staff member said, “If someone hasn’t opened their bowels for 2–3 days, the system flags it, and we discuss it during handovers so nurses can intervene. Most residents are already on PRN laxatives to help prevent constipation.” Another staff member added, “If a resident has a fall or any incident or concern, we share it in the handover meeting and the 10:11 meeting, and we document it on the system. We talk about what has been done and what still needs following up.”

Daily meetings and handovers were held, providing opportunities for staff to raise and discuss issues related to people’s care and any incidents that had occurred.

However, staff did not always make full use of these meetings to report concerns, which meant that proactive measures were not consistently taken to address issues before they escalated or to prevent near misses. For example, staff had observed that some individuals had not opened their bowels for several days, but these concerns were not raised during handovers to ensure timely follow up. One staff member told us, “I think we could improve how we share concerns or incidents. If you’re not present at the handover, you don’t really know what has happened or what needs to be done. I usually ask, but not everyone will.”

When incidents and concerns were escalated to the management team, including the service director, they were investigated, outcomes were communicated to staff, and actions were put in place to prevent recurrence. For instance, after we raised concerns about mattresses not being correctly set, systems were introduced to address the issue and ensure people received appropriate support in managing their weight.

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.

Staff worked closely with people, their relatives and other services and professionals to ensure people received effective and timely care, including pre-admission assessments, continuity of care during transfers, and reassessment following hospital admission. Partnership working with professionals ensured timely access to equipment and appropriate placements, supporting people’s safety and wellbeing. Experienced staff assessed individuals’ needs to confirm they were suitable for the service and that their care could be delivered safely. The service also had a system in place to reassess and review people’s needs before they were readmitted to the service following a hospital stay.

Staff liaised with professionals and external services to make sure people had the necessary equipment and that their safety was maintained. One relative told us, “My loved one needed more support than we could provide at home. The staff here made it easy. They came to our home to discuss everything and arranged all the support when my loved one moved in.” A professional also shared how they had worked with the home to identify a suitable alternative placement that met the person’s needs.

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 they felt safe in the service. One person said, “Yes, I certainly feel safe here.” Another person commented, “Yes, I do feel safe.” A relative mentioned, “Loved one really enjoys that they live there. They feel very safe and it gives me peace of mind.”

Staff had completed training in safeguarding people from abuse and knew the signs to recognise if there was abuse and the actions to take. They told us they would report any concerns to the manager whom they knew would take necessary actions. Staff knew how to whistleblow and told us they would do so if they need to in order to safeguard people.

The registered manager, deputy manager and service director demonstrated they understood their responsibilities to safeguard people from abuse. We noted they had taken appropriate actions to address allegations of abuse involving the service including raising safeguarding alerts to the local safeguarding team, carrying out investigations and where necessary involving relevant agencies such as the police and notifying CQC.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

People had valid DoLS in place or a pending application with the local authority. The registered manager understood their responsibility to promote people’s rights and they notified CQC of any approved DoLS as required. Staff had been trained in MCA and understood their responsibilities.

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.

The risks associated with constipation were not managed safely or effectively. During the visit, bowel records were reviewed and showed that three individuals had not had a bowel movement. Records indicated that one individual had not opened their bowels for 10 days, another for 5 days, and a third for 4 days. Risk assessments for these individuals highlighted that they were prone to constipation, and they had been prescribed laxatives on an as‑required basis to help manage this condition. However, a review of the medication administration records revealed that staff had not administered these prescribed medications during the relevant periods until we raised our concerns with them.

Daily care notes for 1 individual documented that they had complained of abdominal pain on at least 3 occasions over a 4‑day period in which they had not opened their bowels. The notes also recorded changes in their eating habits and mood. Despite these symptoms, staff administered paracetamol rather than considering the use of the prescribed PRN laxatives or investigating the underlying cause of the person’s discomfort. This was particularly concerning given that the same individual had experienced constipation lasting 6 days within the previous 2 weeks, during which they had reported similar symptoms.

We raised this with the registered manager on the day, and they immediately requested that the individual’s PRN laxative be administered. We checked the next day and confirmed that the person had subsequently opened their bowels. The registered manager also informed us that new systems had been introduced to ensure this risk is managed more effectively going forward.

We found that individuals at risk of developing pressure sore were provided with pressure‑relieving mattresses (airflow mattresses) to help reduce this risk. These mattresses are designed to prevent pressure ulcers, enhance comfort, and promote better circulation for people who spend extended periods in bed. However, we found that several mattresses were not set correctly in line with the manufacturer’s instruction which can significantly reduce their effectiveness.

We found that repositioning charts were not consistently completed to confirm that people had been repositioned to relieve pressure points and minimise associated risks, although none of the individuals had pressure sores at the time.

Other areas of risks to people were managed effectively. We noted catheter risk assessments contained information to help reduce risks. We observed staff following safe moving and handling procedures and people at risk of malnutrition were supported to manage this risk.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety checks and environmental risk assessments were carried out, covering areas such as fire safety, electrical installations, gas safety, portable appliance testing and water management including legionella. The fire risk assessment for the home was up to date, and an action plan had been developed following the most recent fire safety inspection, with recommendations actively being implemented.

Health and safety equipment used in providing care, such as hoists and wheelchairs, was checked and serviced regularly. We noted that the Arjo bathroom had not been serviced recently, although it was not currently in use. The registered manager explained that people preferred showers rather than baths. However, they confirmed that plans were in place to continue servicing the equipment to ensure it remained available should it be needed.

Staff were not always effective in their roles. There were enough staff available to support people.

Training records showed that staff had received the necessary training for their roles, and relatives we spoke to shared positive feedback. One relative told us, “Most of the care staff are knowledgeable and skilful.” Another commented, “I do not have any issues with the care staff. They are definitely well-trained.”

Staff also confirmed they had completed the required training. One registered nurse said, “The deputy manager, who is also a qualified nurse, gives me regular supervision. They are always up to date with everything.” Another registered nurse added, “The deputy manager supervises me and always checks how I’m doing. If there are any problems, we discuss them. I’ve completed all the required training, and any additional training that’s recommended, I do it.”

However, concerns remain regarding the effectiveness of training and staff competencies. For instance, while records indicated that staff had completed training on constipation management, we found that when individuals exhibited symptoms of constipation, staff did not consistently interpret these signs accurately or provide the necessary support. Two professionals also provided feedback regarding lack of staff confidence and knowledge in supporting individuals with nutritional needs and those receiving end-of-life care.

There were enough staff available to support people with their needs. People, their relatives and staff told us staffing levels had improved since the new provider took over. One person told us, “There are staff around. They come in to attend to my needs. When I call or request for something they respond within a reasonable time. I don’t wait for too long.” We observed that adequate staffing levels were maintained, comprising both nursing and care staff. Staff responded to people’s needs and requests for assistance promptly. Staff were available in communal areas and people who were cared for in their rooms received support they needed with their personal care, eating and carrying out activities.

Staff told us there were enough staff to safely support people. One member of care staff said, “Staffing is okay - sometimes is it really busy because things happen during the day that’s not planned but they try to find extra staff to help. Sometimes they succeed and some other times we just have to manage because it's usually too late to find a cover.” Another member of staff told us, “Staffing levels are enough currently based on the number of people. When the patients increase, they will increase the staffing too. The deputy manager is always on ground to help, and we work as a team.”

Robust recruitment checks were conducted before applicants could work with people. These included criminal records checks, references, employment history and right to work in the UK. Records showed that registered nurses were up to date with their professional registrations, which remained valid.

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 had infection prevention and control (IPC) systems in place. Staff were well trained and followed established procedures. The environment was clean, odour‑free, and well maintained. Infection risks were monitored and controlled through regular audits and checks.

Staff had received training in infection control and understood how to reduce and manage infection risks, including how to escalate concerns. During the inspection, we observed staff using personal protective equipment (PPE) appropriately and practising good hand hygiene. Clinical waste was handled safely. Catering staff were trained in food hygiene and used suitable PPE while preparing meals.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff did not always follow prescribers’ instructions when administering medicines. For example, one person’s medication was required to be given 30–60 minutes before consuming food or drinks containing caffeine. However, on at least three occasions, the medication was administered after the person had already eaten breakfast or had a drink.

Protocols in place for ‘as when required’ medicines were not always consistently clear or detailed to clearly define in accordance with best practice guidance when and how to give medication, detailing the medicine, dose, frequency, and the specific symptoms/cues for use, alongside non-drug alternatives to try first (like comfort measures), maximum daily dose, and expected outcomes. For example, 1 person’s protocol for a medication to manage anxiety stated, ‘To treat for anxiety, restlessness half to 1 tablet 3 times when needed.’ There was no information to help identify signs or symptoms of anxiety and what other strategies to try first before the use of medication. Another person’s medication protocol for treating constipation stated: ‘Macrogol compound oral powder sachets NPF – 1–2 sachets. Assess for bowel action, constipation, and abdominal pain.’ No further information was provided. Care plans did not always indicate where to apply people’s topical creams.

Only qualified nurses administered medicines to people and medicine administration record charts were maintained and signed to show medicines administered.Medicines were stored within safe temperature ranges, in line with the manufacturer’s instructions. Regular checks were made of storage temperature areas to ensure they remained safe. There were systems in place for receiving medicines into the home, safe storage and safe disposal of medicines.