Moorfield House

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 the last inspection we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 62 (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 and registered manager had developed a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. For example, the registered manager had used information from their review of incidents and lessons learnt to ensure the concerns raised at previous inspections about managing choke risks were resolved.

Staff 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. The registered manager closely monitored how people settled in the home and if the placement continued to meet their needs. Where people experienced periods of distress, there was not always information in place to enable staff to support them effectively. The registered manager had not been made aware of this issue so was unable to closely monitor situations such as this. The registered manager took immediate action to ensure staff consistently recorded information about people’s needs. A relative said, “The staff made the move to the home seamless and were good at making [person] feel at ease.” Another relative said, “I was impressed [registered manager] came to do a home visit before [person] arrived. Also, when I called to make an appointment to initially visit they said I could drop in anytime - I was amazed as the other places we had to make an appointment.”

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 registered manager shared concerns quickly and appropriately. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. Deprivation of Liberty Safeguards (DoLS) authorisations were sought when needed and any conditions imposed by them were followed.

The staff team worked with people to understand and manage risks. Appropriate action was taken to ensure people were safe. However, staff needed additional support to assist them understand how to gather, analyse information in order to ensure they created robust risk assessments, particularly in relation to working with people who displayed distress reactions. Whilst staff discussed incidents and talk through their experiences, formal debrief procedures were not in place. Neither were mechanisms to assist staff deal with the odd occasions when they and others had been assaulted. The regional manager and registered manager took immediate action to address these matters.

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. Environmental risks were not fully assessed and addressed. The home consists of 3 floors with useable communal space only being available on the ground floor. Whilst most people spent their day downstairs some people chose to stay in their rooms. Due to the lack of a hot lock, which would fit in the lifts, and no tea making facilities on each floor, staff were taken away from each floor to carry meals and drinks up the stairs. A risk assessment was available, but this covered periods when the lift was broken rather than the customary practice of staff taking trays with people’s meals and drinks on up two flights of stairs. This meant there were periods when no staff were available, and it also posed risks related to staff safety and appropriate food management. The regional manager immediately purchased a suitable hot lock, installed tea making facilities and made sure staff had a space on each floor to sit when observing people overnight and to complete their records. They also ensured equipment in the kitchen were repaired and an air conditioning unit fitted to the storage area. The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed. People were supported to be as independent as possible within the environment.

The provider and registered manager made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. At 7am there was a changeover of nurse and senior carer, and the remaining day care staff started at 8am. Whilst these staff, and the registered manager, were on the premises it was unclear how they worked together to ensure everyone was supported. We heard for some shifts in that hour the 3 night care staff were completing all the personal care tasks across the home with little to no support. We discussed this with the registered manager who immediately took action to address this matter. A person said, “Mostly the staff are there if we need a hand, however during their meal breaks and on a morning, we do have to wait longer.” A relative said, “It is a matter of concern that there has been no deputy manager for three years; the two who have been appointed in that time have left very soon after beginning work.” There had been a number of vacancies including a deputy manager which the registered manager was resolving. The registered manager had appointed a deputy manager who was undergoing recruitment checks and was expected to take up their role shortly.

We found recruitment practices were meeting requirements. The administrator closely monitored compliance with recruitment requirement and that the nurses continued meet the Nursing Midwifery Council requirements for registration as nurses. The provider promoted a learning culture and ensured staff had access to a wide range of training. Staff had received mandatory and condition specific training. Staff supervision sessions were completed in line with the provider's policy.

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. Staff followed the required infection control guidelines.

Staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff who administered medicines had the appropriate training and competency checks. Staff worked closely with the GP and pharmacist to make sure medicines were managed appropriately.