Archived: Manor Park 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. At our last assessment we rated this key question Good. 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 regulations in relation to safeguarding, medicines, risk management, infection control and staffing.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have proactive and positive cultures of safety based on openness and honesty. They did not always fully investigate safety events and lessons were not learnt to continually identify and embed good practice.

Events had not been effectively and robustly reflected upon and used to drive improvement. There was a lack of oversight and monitoring of lessons learnt, and it was not clear what action was taken following accidents and incidents. Some relatives told us when they had reported concerns or made requests for improvement in the care provided, they were not listened to and improvements had not been made.

The provider did not have systems in place to ensure the needs of people moving into the service had been consistently or safely assessed. They did not make sure there was continuity of care, including when people moved between different services.

Systems and processes for admitting people into the service were not robust to ensure their safety. Pre-admission assessments were not always completed by the provider, prior to people moving into the service. Where pre-admission assessments had been undertaken these were not thorough. For example, one person’s pre-assessment had not been fully completed to ensure and demonstrate the service could meet the person’s needs. The person told us they were unhappy at the service and felt their needs were not being met. Staff acknowledged the person was not appropriately placed. Professionals were now working with the person to find an alternative placement.

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 always share concerns quickly and appropriately.

The provider failed to identify and address restrictive practices that were in use at the service. For example, staff told us 1 person was kept in bed because their distressed emotions affected others when they were sat in a communal area. There was no evidence to show any referrals had been made to look at different options for this person. Three other people had to share a specialist chair which meant when 1 person was using the chair, the other 2 people had to stay in bed. We made safeguarding referrals following our site visits.

Staff had completed safeguarding adults training however this was not effective as accepted restrictive practices at the service had not been recognised or reported.

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.

Some people and relatives said the service was safe, however others felt their family members were not always kept safe. Our observations showed risks to people were not well managed. We observed a lack of staff supervision for 1 person, who was at a high risk of falling, and sensor equipment was not being used despite care records stating this was required. We observed 2 other people were not wearing appropriate footwear increasing their risk of falls.

Three people, who were at high risk of pressure damage, were not being repositioned in accordance with their care plans. Repositioning records for 1 person showed gaps of up to 9 hours, when they required 4 hourly repositioning.

People who were known to be at high risk of choking were not managed safely as they were not positioned correctly when eating and drinking.

People did not always have access to call bells in bedrooms or lounges and dining rooms, meaning they were unable to summons assistance from staff.

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

We observed the majority of people on the nursing unit remained in bed during the day. Staff told us there were not enough specialist chairs for people who needed this type of equipment to ensure they could sit out safely. Action was taken by the provider following our initial inspection feedback.

Areas of the home were in need of redecoration and refurbishment. Several bathrooms were inaccessible and out of use. We saw boxes of continence pads stacked up in people's ensuites and bedrooms, limiting access to facilities. The environment was not dementia friendly with several bedrooms having no names or pictures on the doors to help people locate their rooms. On the dementia unit bathroom doors had pictures on, however the doors were locked so people could not access the facilities.

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.

People and relatives raised concerns about staffing levels. Comments included, “When I come to see [family member] they’re usually in the lounge and no staff are there”, “I think they’re definitely understaffed” and, “I don't think there are enough staff. I had an issue recently when I had a bath and no one was about to help me get out. I was really unhappy and annoyed about it, that I was just sat there for ages.”

Staff said they had raised concerns with management about staffing levels and felt they had not been listened to as the situation remained the same. During all 3 site visits, inspectors had to intervene and alert staff to people’s needs. Staffing levels were increased following our initial feedback, however deployment of staff remained an issue. We observed people were at risk of not receiving the care and support they required as agency staff, who were not familiar with people or the service, were left working alone while permanent staff worked together.

The provider’s training matrix showed not all staff had completed up to date training or had been assessed as competent to carry out their roles. This included mandatory training in practical moving and handling, fire drills and evacuations as well as medicine competency assessments. This placed people at risk of harm.

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. We observed the morning medicines rounds scheduled for 8am and 9am were completed at 12.57pm. In addition, records showed medicines were recorded as regularly being administered late, especially in an evening. We could therefore not be assured safe systems and processes were in place to ensure people received their medicines in a timely manner or that the provider’s governance arrangements were robust enough to recognise and correct this.

The provider could not demonstrate people were being given their medicines as prescribed, because some medicines, including critical medicines, were out of stock. It was not always clear from the records what action staff had taken to ensure medicines were available.

Reports on the electronic medicines system showed medicines stock adjustments occurred regularly. For example, we saw 1 person’s medicines stock levels had been adjusted and the amount decreased, however the medicines were in the overflow cupboard. This meant it was not clear whether there was a robust stock management process or that stock levels accurately reflected what was at the service.

Topical medicines such as creams were stored in people’s bathrooms; we raised concerns during our site visit about the risks associated with accessibility to creams, especially on the dementia unit.

The majority of medicines were stored securely in treatment rooms; temperature monitoring was in place. Controlled drugs were recorded accurately, and checks were recorded twice daily.

Monthly medicine audits did not identify all the areas of concern we found during the assessment. In addition, some lines were identified in the audit as achieved however additional comments were made regarding mitigation or non-compliance therefore suggesting a rating of not achieved.

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. We observed the morning medicines rounds scheduled for 8am and 9am were completed at 12.57pm. In addition, records showed medicines were recorded as regularly being administered late, especially in an evening. We could therefore not be assured safe systems and processes were in place to ensure people received their medicines in a timely manner or that the provider’s governance arrangements were robust enough to recognise and correct this.

The provider could not demonstrate people were being given their medicines as prescribed, because some medicines, including critical medicines, were out of stock. It was not always clear from the records what action staff had taken to ensure medicines were available.

Reports on the electronic medicines system showed medicines stock adjustments occurred regularly. For example, we saw 1 person’s medicines stock levels had been adjusted and the amount decreased, however the medicines were in the overflow cupboard. This meant it was not clear whether there was a robust stock management process or that stock levels accurately reflected what was at the service.

Topical medicines such as creams were stored in people’s bathrooms; we raised concerns during our site visit about the risks associated with accessibility to creams, especially on the dementia unit.

The majority of medicines were stored securely in treatment rooms; temperature monitoring was in place. Controlled drugs were recorded accurately, and checks were recorded twice daily.

Monthly medicine audits did not identify all the areas of concern we found during the assessment. In addition, some lines were identified in the audit as achieved however additional comments were made regarding mitigation or non-compliance therefore suggesting a rating of not achieved.