Maristow 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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires 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 to safe care and treatment.

This service scored 47 (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 investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Incidents, accidents and events were not always being identified or investigated, and lessons learnt were not being considered. For example, care records demonstrated multiple bruises people had sustained but the records only stated ‘unwitnessed’ and ‘monitor’. There were no further details such as a description, potential causes or action taken.

Records showed some bruising was reported as an incident, but others were only documented in the person’s care plan. This was inconsistent and meant bruising was not analysed to identify trends and whether adequate action was taken or reported appropriately.

Incidents of unexplained bruising had not always been reported to the local safeguarding team or to CQC. This did not demonstrate transparency or ensure appropriate investigation. Leaders were aware of their responsibility to report those incidents we identified in people’s care records.

There was not an effective system to identify and share learning with the wider staff team. Some staff told us they would be told in handover if an incident occurred, whilst others referred to a communication folder. Staff said they were supposed to sign the record, but not all had done so.

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.

Records demonstrated people were referred to other healthcare professionals when needed and a GP visited the service weekly. This enabled people’s health to be monitored and their medicines to be regularly reviewed. Staff told us it was easy to contact a health professional for advice between the weekly visits.

Staff told us they worked well with health and social care professionals, and good working relationships had been established. There were clear processes to ensure people’s personal information was shared safely.

People were assessed before being offered a placement at the service. This included gaining information from involved health and care professionals as needed.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

The management team did not understand their responsibilities regarding the action to take to protect people from harm. This was because there were examples where action had not been taken to protect people where required. Necessary internal documentation was not always completed such as incidents reports.

The provider was not aware of some bruising people had sustained, so further action to identify the cause or minimise further occurrences had not been undertaken. The provider had not ensured referrals and notifications were consistently made to the local authority or safeguarding teams in a timely manner.

The service did not have a restraint policy, but restraint had been used when supporting a person. Staff told us they had been shown how to use restraint by the provider and training co-ordinator, but they had not received any formal training. This was unsafe, and we referred the incident to the local safeguarding team. The provider had already reported the incident, and an investigation was being undertaken.

There were safeguarding and whistleblowing procedures, and staff had received safeguarding training. Staff told us of the importance to report potential abuse and take photographs, which might need to be shown to the safeguarding team.

People told us they felt safe at the service, and relatives had no concerns about safety. One relative told us, “They know [family member] so well, they know them inside out, I can relax knowing they are safe and well looked after. They are all so amazing.” Another relative said, “At the last service, [family member] didn’t feel loved or safe but they do here.”

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.

Risks people faced had been identified and assessed, but care plans did not consistently provide clear guidance to staff on how to mitigate them. For example, care plans did not always inform staff how often a person at risk of skin damage, needed support to change their position. This direction was not stipulated on a person’s position change chart, even though there was a section on the form for this.

Records demonstrated some people had trouble swallowing, but the risk of choking had not been formally assessed. Care plans did not inform staff of all steps they should take to prevent a choking episode, or what to do if someone did choke. However, referrals had been made to the speech and language team (SALT) for advice, and recommendations made were documented in people’s care plans. Staff knew how to reduce the risk of choking including positioning and supporting people with eating and drinking slowly.

People had been assessed regarding their risk of malnutrition, falls and the use of bed rails. Risks for people who smoked, had also been assessed. Plans of care to support people who experienced periods of anxiety or agitation were detailed and followed in practice.

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

There were aspects of the environment which were not safe. For example, the water from handwash basins in people’s bedrooms and communal toilets was excessively high and there was a hot water urn in the corridor next to the lounge. The hot water from both systems, placed people at risk of scalding. The provider told us the urn was locked at 70 degrees and believed an accident would cause pain, rather than a significant burn, but this was not accurate.

The laundry room and the cleaning cupboard used to store chemicals, were not secure and there were cleaning substances around the service. A toilet on the first floor, which people used, housed a sluice machine. These risks, including people digesting the substances and inappropriately touching the electrical appliances, had not been considered.

Not all windows had been fitted with restrictors, which meant there was a risk of people falling from height. This was particularly so for those windows on the first floor, which could be opened fully. The provider told us they assessed this risk on an individual basis with people, but they did not have documentary evidence of this.

The service was not well maintained. There was an electrical socket that was loose, 2 radiator covers were damaged and 1 in a room, not currently being used, was broken. The door to the main lift did not close properly.

Some carpets were threadbare and frayed in places, and other flooring was not intact. This posed trip hazards, and there was large furniture such as wardrobes, which was not attached to the wall. There was a lower patio at the lounge door for people to use as they pleased. However, the rest of the garden was overgrown and not an inviting or safe space.

Staff told us they had repeatedly raised concerns about the environment. One staff member told us, “I would like the garden to be made available again. We had a lift, but it broke down and it’s too expensive to fix.” Another staff member told us radiator covers were broken, the whole building needed re-decorating and the carpet on the first floor needed replacing.

Relatives agreed the home needed redecoration but said it was homely and comfortable. 1 relative told us the homely environment was what attracted them to the service initially. They said, “It just wraps around you like a big cosy hug.”

After the inspection, the provider told us they were taking action to minimise the risk of the hot surfaces and hot water. They said they were gaining quotes and formalising an action plan regarding all other shortfalls with the environment.

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.

Leaders told us they did not have a specific dependency tool to assess the numbers of staff required. They said they knew their capacity, kept empty rooms and only accepted 1 person with complex needs at a time. Leaders told us they regularly monitored the general atmosphere of the home and would make changes to staff deployment if it became busy.

There was a staff presence and call bells were answered in a timely manner. Staff told us they felt there were enough of them to meet people’s needs. This included 1 staff member who said, “Yes, we're a small home, we have enough.” However, people’s feedback about staff availability was varied. Specific comments included, “More staff are needed,” and “Staff do not pop in and chat as they are too busy.” People did not raise concern that this had impacted on their needs being met.

Records demonstrated staff received regular training and staff told us they felt trained to carry out their roles. They told us the training co-ordinator on site let them know when refresher training was due. Nurses told us they had access to additional training to meet their registration requirements.

Staff told us they felt supported, but they did not have formal documented one to one supervision meetings with their line manager. This did not enable staff to have protected time to discuss their roles or any training needs or concerns. One staff member us, “We do have [supervisions], but they are not documented, because [provider] comes on the floor to speak with us. His door is always open though, and we can always access him.”

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

The environment was worn with stained carpets and chipped paintwork. This meant it was difficult to keep hygienically clean and free from cross contamination. We observed not all bins were pedal operated, and not all paper towel dispensers were covered. This increased the risk of cross contamination and meant the clean paper towels were at risk of contamination.

Records did not demonstrate people’s bedrooms were deep cleaned regularly. This did not ensure all areas of each room were clean. Additional risks of worn fixtures and fittings increased the risk of cross contamination. One staff member told us, “It is hard work trying to keep it clean.”

We observed one person emptying their catheter bag into a rain drain adjacent to the lounge door. This was unhygienic, undignified and posed a risk of infection. Leaders were aware the person did this but had not stopped it happening.

However, equipment to move people safely was visibly clean and there were housekeeping staff on duty 7 days a week. Staff told us they had the equipment and cleaning substances required to do their job effectively. Records showed staff had received training in infection prevention and control. Staff demonstrated they knew when and why they needed to use personal protective equipment (PPE) and there were enough supplies for them to use.

People told us they were happy with the cleanliness of the environment. Specific comments included, “They keep everything clean,” “They clean my room most days” and “There is a lovely girl that I see cleaning all the corridors and bathrooms.”

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

Staff were not monitoring the temperature of the cupboards where medicines were housed, or the minimum and maximum temperature of the medicine’s fridge. This did not ensure medicines were consistently stored at the manufacturer’s recommended temperature and therefore safe to use.

There was no guidance to inform staff how to apply topical creams and their competence to do this safely, had not been assessed. Not all items had been dated when opened, which increased the risk of expired items being used.

There were records to demonstrate the decision-making process to crush some medicines or give them disguised in food, known as covert administration. However, the records were dated 2023 and not all medicines listed, corresponded with those the person was receiving. This did not ensure the medicines were given safely or lawfully.

The provider’s policy regarding homely remedies was not always being followed. This was because staff had administered homely remedies to other staff on duty, and 1 person was given a medicine that was not on the approved list signed by the GP. The stock balances of 2 of the homely remedies were incorrect, but this had not been identified. This did not ensure accurate administration or monitoring.

Records demonstrated some people were prescribed medicines for periods of anxiety and agitation, but staff had not documented if the administration was successful. This did not enable the effectiveness of the medicine to be established to ensure it remained appropriate for the person’s needs.

There was a policy for the safe management of medicines for staff to refer to as needed but it was not up to date. This was because the information referred to the nurses’ previous professional body, not the Nursing and Midwifery Council.

However, staff had received training in medicine administration, and their competency had been assessed. Records demonstrated any errors with medicines had been reported and investigated appropriately. Any action required to minimise a reoccurrence were shared and discussed with other nurses.

People had their medicines regularly reviewed to ensure they remained effective. One person told us they held their prescribed medicines in a locked drawer in their room. They said staff supported them to take their medicines safely.