Middleton Manor Care Centre

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 service since a change to their registration. This key question has been rated 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 people’s safe care and treatment including medicines management, managing risks to people and the environment, infection prevention and control, safeguarding and staffing.

This service scored 31 (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.

We reviewed the provider’s processes for managing safety concerns at the service and their complaints file. A complaint we reviewed was in relation to pain medicine not being available. This had happened on 2 separate occasions despite the relative flagging this the first time it happened. During our inspection we found further examples of medicines being out of stock. This demonstrated a failure to learn from incidents.

We found the provider had not learned from the findings of their fire risk assessment as fire drills with night staff had not been completed in line with recommendations.

Systems for recording accidents and incidents in the home were inconsistent. We found some incidents between people who used the service had not been recorded in-line with the home’s processes or escalated to senior staff, therefore appropriate actions had not been taken to manage ongoing risks.

We received mixed feedback from staff about learning from incidents. A member of staff told us, “Learning from accidents and incidents is not shared.”

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. They did not always make sure there was continuity of care, including when people moved between different services.

Systems in the home did not always support safe care and continuity for people. Care records had been regularly reviewed but these did not always reflect current needs, recent incidents or measures to manage risk.

Medicines systems did not ensure people had the right medicines at the right time. Healthcare professionals had not always been consulted when medicines errors or omissions had occurred. There was a lack of consistent recording around the use of thickeners for drinks, and this had not been identified in management checks of the service.

We found some examples of staff making appropriate referrals to other professionals and sharing information. While we were in the home staff contacted them with people’s health updates. However, incomplete record keeping meant we could not always be assured the home was working with healthcare partners appropriately, consistently reporting concerns about risks or ensuring continuity of safe care.

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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

During the assessment we identified several safeguarding concerns that the registered manager was not aware of and had therefore not been reported to the Local Authority or, where applicable, the Care Quality Commission. We requested that these were reported retrospectively, however, this was not done in a timely manner, and we had to repeat this request to ensure all safeguarding referrals were submitted.

Some staff told us they had confidence any concerns raised would be acted on, but others told us they did not have confidence about people’s safety or concerns being addressed. A staff member told us, “If I were concerned about abuse, I would raise my concerns with the manager whether she wanted to speak to me or not, and if I felt my concerns were not listened to, I would take the matter further. In the hands of [the registered manager] I do not feel my concerns would be acted upon.”

We reviewed the services Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training and noted 10 out of 54 staff had not fully completed training in these areas. This posed a risk with staff potentially not being able to appropriately identify restrictive practice and not know which people lacked capacity and needed support to make day to day decisions. A relative told us, “I was given incorrect information by [a member of staff] when I was there the other day about [my family member’s] DOLs assessment - it didn't matter but it was a little irritating.”

Most relatives told us they felt people were safe. A relative told us, “There was an incident with another resident, however, I believe that although that was distressing they handled it well and put in measures to prevent a recurrence.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People were at increased risk in the event of a fire because not all staff had taken part in fire drills to practice fire procedures and evacuation. Fire drills that had taken place recently did not include all night staff and had not demonstrated that people could be evacuated safely and in a timely way.

We observed risks to people that were not well managed. For example, a person who was at high risk of falls was walking around the home in only socks. Their risk assessment clearly stated they needed to wear appropriate footwear to reduce the risk of falls. Another person who was at high risk of falls did not have footplates on their wheelchair which increased their risk of injury and discomfort. This was observed on 2 of our visits to the home and there was nothing in their risk assessment regarding this. People were not always given enough support at mealtimes, increasing risks around poor nutritional intake or choking.

Some people in the home posed a safety risk to others either because of their current level of agitation and anxiety or because of their historic patterns of behaviour. Risk assessments did not always describe how these risks would be managed and reduced. For 1 person care plans were very detailed. However, when we observed this person being supported the documented strategies were not effectively followed and this person became distressed.

We receive mixed feedback from relatives. Some felt risks were well managed but others raised concerns. For example, a relative told us, “I’m happy that [my family member] is safe, I have been there when they are fed, moved and cared for and I believe that they are safe.” However, another said, “I have concerns that my [family member] is not checked frequently enough. They spend a lot of time in the garden alone where staff cannot see them.”

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.

Storage in the home was not always safe. Prescribed medicines and other personal items were in a communal bathroom which was being used for storage, and this had been left unlocked. This bathroom was in a part of the home where people were living with dementia and people spent time walking in the corridors unobserved by staff. This posed a risk that someone could ingest these medicines.

There was a programme of safety checks in the home including water temperatures, equipment, lighting, alarm bells, bedrails and these had all been completed as planned. Regular checks were made on the safety of the environment, but these had not identified the issues with safe storage we found at this assessment. These checks were completed by senior staff and there was no evidence the registered manager was regularly checking the safety and security of the environment.

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.

There were not always enough staff. Most relatives we spoke with told us they had concerns about staffing and deployment. Their comments included: “There are regular issues, there often doesn't appear to be enough staff and not enough staff to do the jobs. There are very busy communal areas, I’ve been left alone in there while staff are dealing with other people”. Another relative said, "[My relative] needs support to use the toilet and if 1 of the 2 staff are on a break they’re told they have to wait." Some staff also expressed concerns about staffing, they told us, “Not enough staff. I feel like the staff are expected to do too much with no help and support from senior staff.”

Staff were not always deployed safely. An area of the home was only staffed with 1 staff member who had to wait for assistance from staff working in other parts of the home if they needed help with tasks. This meant that people had to wait for support. It also posed a risk to the staff member in the event of an emergency. In other parts of the home, we observed that people were not always supported appropriately at mealtimes. Some people had to wait for staff to assist them with their meals.

Staff were not always skilled and experienced to meet people’s needs. Staff did not have training around Parkinson’s, positive behaviour support or end of life care. Relatives told us they felt staff sometimes did not have the knowledge around their family member’s individual needs. One relative told us, “A little tuition in how to care for problems the residents have could improve their understanding of how to look after them.”

Staff gave mixed feedback about training. Some felt they had the right skills and knowledge; however, others told us this needed to improve. A staff member told us, “I have had training in previous jobs but not had any in Middleton Manor, I’ve not even been put through my moving and handling or any of the training required for my role.”

Some staff told us they felt supported, but others said they did not feel they had enough support or opportunity to discuss their training and development. Staff had not had regular formal supervision and appraisals. A staff member told us, "I have asked for training to support my job role but nothing came of it, it is always like the management are too busy to listen to the staff.”

Staff recruitment processes were in place, but these had not always been followed to ensure appropriate checks had been made about people’s past employment. Where staff were employed without relevant training or experience it was not always clear how this would be addressed to ensure they had the knowledge to carryout their roles successfully.

The provider did not appropriately assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed many areas of the home were in need of a deep clean, bathrooms and toilets were dirty and cluttered with items, increasing risk of cross contamination. In 1 area floors were sticky and we found a medicine spoon and empty syringe left on the floor.

Monthly audits had highlighted the need to improve cleanliness every month since January, but insufficient measures had been put in place to address this.

We had mixed feedback from people’s relatives about the cleanliness and infection control measures in the service. A relative told us, “In general the communal areas, kitchen, front reception are clean. We have had problems with [my relative’s] room, and raised concerns, several times." Another told us, “Frequently my [relative] runs out of hand towels and toilet tissue in their room.”

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

Medicines were not managed safely at the home. Medicines were not always stored securely, and temperatures were not always monitored in line with the home’s policy.

We could not be assured that people were receiving their medicines as prescribed. Stock balances for some medicines did not match computer records. Where missed doses were identified no incident forms were completed or investigations documented. We saw that medicines administration records had been amended retrospectively with no documented investigations to check if the medicines had been administered. Systems to ensure medicines did not run out were not effective. Out of the 16 people we reviewed 9 were prescribed medicines which were out of stock.

Medicines were not always given safely at the correct time. A relative told us, “My [relative] needs their medication to be given on time to maintain their mobility. This does not always happen and some of the senior carers are a bit rough with them when doing so.” Another relative told us, “A medicine [my relative] takes is anti-seizure medication and as they were not given it correctly my [relative] did actually have a seizure the next day.”

Where medicines were administered via a patch, the site of application was not safely rotated in line with the manufacturer’s instructions even though specific patch application records had been supplied to improve the recording.

Thickening powders which are used to thicken drinks to prevent choking were not managed well. 1 person did not have any thickener available. Records for other people were not completed accurately.

The process for the ordering and disposal of medicines was not robust. Controlled drugs (medicines liable to misuse) were not safely recorded when disposed of and therefore could not be accounted for.

Internal and external audits had identified medicines concerns. However, actions had not been recorded on the home’s wider improvement plan, and we could not see evidence that actions had been taken to make the necessary improvements.

A staff member told us, “Medications are poorly managed; we frequently run out of stock. When I bring these concerns to management I am consistently told it is my responsibility. When I attend my shift, I complete a full medication count and ensure that everything is correctly recorded, often when I return to work following days off the medications do not tally, stock is incorrect and there is an abundance of missed meds.”