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 inadequate. 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 continued breach of legal regulation in relation to staffing.

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 was beginning to embed a proactive and positive culture of safety based on openness and honesty. However, 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.

There were missed opportunities for the provider to learn lessons and improve practice. When incidents of concern occurred, such as falls or unexplained bruising, systems and processes for investigation and reporting were not always robust. The manager told us they used forums such as staff meetings to discuss learning from incidents and were working to develop a learning culture that encouraged open and transparent communication.

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.

Systems and processes were in place to ensure people were safely admitted to the service. Pre-admission assessments were completed and discussed by the manager and deputy manager prior to a person moving in, to ensure their needs could be met. This included the provider visiting the person and meeting them face-to-face. People were supported to access healthcare professionals and other health care services when needed.

The provider mostly 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. However, the provider did not consistently share concerns quickly and appropriately.

People were mostly safeguarded from the risk of abuse. Staff participated in safeguarding training and actions were implemented to protect people from the risk of harm. However, we found an example of a serious injury that had not been reported to the local authority or the Care Quality Commission. This had not been picked up by the provider’s internal quality checks. Improvements were needed to ensure all notifiable incidents were appropriately reported.

The provider did not always work well with people to understand and manage risks. Staff did not consistently provide care to meet people’s assessed needs.

Risks to people’s health and safety were not always effectively assessed, monitored and mitigated. This included risks associated with skin integrity and insufficient fluid intake. For example, 6 people’s pressure relieving mattresses were not set to the correct weight and 3 people had not been repositioned in line with their assessed needs. In addition, 1 person who was assessed as needing to be repositioned every 4 hours, had numerous occasions where this had not taken place. On 1 occasion they had not been repositioned for over 46 hours. This placed people at risk of harm in relation pressure damage. Furthermore, 1 person’s care records detailed how they required fluid monitoring and had a fluid target of 1200mls per day. Records showed over a 2-week period the person’s fluids offered and accepted fell well below the target amount. This had not been identified or addressed by the provider prior to the assessment.

Most people’s care plans and risk assessments were detailed, accurate and up to date. There was 1 person however, who had risk assessments overdue for review on the first day of assessment. This had been rectified by the second day. Care records provided sufficient information for staff to support people’s needs safely. However, improvements were needed to ensure that all risks to people were suitably mitigated in practice.

People had access to call bells and staff were aware of who was at particular risk of falls. People had suitable footwear when walking around, although the lack of staff supervision at times meant some risks could not always be mitigated, such as when people were walking in and out of other people’s rooms.

Where people were at risk of choking, staff ensured they were seated safely when eating their meals.

Safe environments Score: 3

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

Systems and processes were operated effectively to maintain a safe environment for people to live in. Overall, the environment was in a good state of repair and there was a plan in place to ensure continued improvements. One person told us "I can get a bath or a shower, but the bathrooms are in definite need of upgrading.” This was being addressed by the provider. Appropriate health, safety and equipment checks were in place.

Specialist equipment was used effectively to enable people to spend more time out of their rooms and in communal areas. One relative told us this had made a huge difference to the quality of their loved one’s day. Improvements had been made to the environment to better support people living with dementia.

People’s safety had been considered in the event of an emergency evacuation, and individual plans were in place.

The provider did not make sure there was suitable deployment of enough staff to meet people’s needs.

Staff were not adequately deployed to ensure people’s needs were effectively met. This was particularly evident on the nursing unit and at peak times during the day. For example, staff were unable to provide prompt assistance for 1 person’s continence needs due to supporting other people’s needs. Another person was continuously calling out for assistance. Staff were not immediately available, and when we spoke with them, they told us they had been incontinent and needed support. One person repeatedly entered the rooms of other people, without being seen or redirected by staff. Staff did not have sufficient opportunity to take their breaks and there were not enough qualified nurses on the night shifts to safely meet people’s needs.

Many people, staff and relatives raised concerns about staffing levels. One person told us, “The staff are lovely, but there are not enough of them.” Another person said, “There are not enough staff, they are always very busy.”

The provider agreed to review their staffing levels following feedback from the assessment.

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 was clean and tidy. We observed domestic staff cleaning throughout the day. Domestic staff were knowledgeable about infection control and had sufficient cleaning materials. There were some isolated areas of malodour which were addressed after the first day of the assessment. Staff had access to appropriate personal protective equipment (PPE) which they used effectively.

The provider made 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 followed systems and processes when ordering, administering, recording, and storing medicines. Records showed that people received their medicines as prescribed and in a timely manner. New systems had been implemented and there was a robust auditing process in place, particularly for time critical medicines. This ensured people received their medicines on time to support the management of their condition.

Medicines were supplied and delivered by a nominated pharmacy and arrangements were in place for obtaining advice and medicines during out of hours. This involved working with other healthcare professionals to meet the needs of the people using the service.

People were appropriately involved in decisions about their medicines and the level of support they needed to manage their medicines safely. People’s preferences were clearly documented in their records. Care Plans and protocols for medicines that are taken ‘when required’ were thorough and contained person centred information on peoples’ specific requirements and supporting documentation.

Temperature monitoring was being completed and recorded in areas where medicines were stored. Expiry dates of medicines were also reviewed regularly. This provided assurance that medicines were safe to use.

Medicines, including controlled drugs were stored securely. Topical creams (non-medicinal) were stored in locked containers within peoples’ bedrooms, ensuring they were stored safely and securely.

Stock was managed effectively and there was good oversight of stock availability. Issues with stock availability were identified early, and actions were taken to resolve these promptly. There was a thorough process in place for monitoring stock levels, ensuring people received their medicines they required to manage their condition.

Staff training for medicines was up to date for almost all members of staff who required it. Staff training and competency was checked for administering medicines annually.

Audits on medicines, including controlled drugs, were thorough and carried out regularly. There was good oversight of medicines.

There was a system in place for reporting medicines incidents. Staff explained how medicines incidents were reported, investigated, and managed appropriately and how learning was shared.