Trafalgar 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 requires improvement. At this assessment the rating has remained 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 clean and suitable premises.

This service scored 50 (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 always have a proactive and positive culture of safety based on openness and honesty. 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.

Improvements were made by the provider on how safety incidents were investigated and reported since our last inspection. However, evidence showed the processes to proactively identify and manage risks before safety events happened were not always effective and fully embedded into practice. This meant not all risks were dealt with and seen as an opportunity to put things right, learn and improve.

At our last inspection we identified that mattresses used to reduce the likelihood of skin breakdown were not always maintained at the correct setting placing the person at risk of harm. At this inspection, we found daily checks the provider had put in place to prevent this from happening again were inconsistent and ineffective. We reviewed records for 4 people who had air mattress on their bed. We found inconsistencies in recording correct settings for eachperson’s current weight, mattress settings frequently not recorded as checked and inconsistencies in recording type of mattress in place for 1 person. There were no records of changing the settings or escalating any issues to the management.

People’s care plans and risk assessments were updated to reflect new learning; however they did not always offer clear guidance for staff on how to mitigate risk and promote safe, person-centred care and support. Care plans for 4 people with pressure relieving mattress in place did not always include clear guidance for staff on what were the correct mattress settings for each person. Staff were working with minimal guidance and had not been supported to mitigate risks to people leaving them at risk of harm such as skin integrity breakdown. This meant people were an increased risk of skin deterioration and pressure wounds.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always effectively 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 and processes to coordinate and maintain continuity of care and support were not applied consistently. Information sharing and communication with healthcare partners and people were not always effective.

Pre-assessment paperwork was completed involving people, relatives and partners prior to people moving into the service, and was shared with staff via the provider’s electronic recording system. Assessments of needs were communicated to staff when people moved into the service or returned from a hospital stay via daily handovers and stand-up meetings. Systems were in place to ensure information was shared with healthcare partners, so people received the care and support they needed in line with their individual plans. For example, hospital passports if they were being admitted into hospital.

However, evidence showed processes of safety and continuity of care through a collaborative, joined-up approach to safety had not always been consistently applied by all staff, nor was fully embedded in the service. Processes did not always involve people in their care along with staff and other partners.

We received mixed feedback from 4 health and social care professionals. Comments included, “We frequently have to chase referrals or specimens that we have asked the home to carry out to be completed. We have to remind and prompt the management team which leads to delays in care and treatment and may result in harm.” [CH1][MF2]

We received mixed feedback from people and their relatives about maintaining continuity of care and their involvement in creating and reviewing people’s care records. Most relatives told us they either did not see their loved one’s care plans or the arranged care plan review was cancelled. Comments included, “There is nothing formally in place and I have not got a copy of [my loved one’s] care plan” and “A review should have been done last week but it didn’t take place.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Whilst overall, staff concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, and discrimination and neglect and shared concerns where required, we found systems and processes were not always robust. The provider did not always share concerns quickly and appropriately.

The provider had safeguarding policies and procedures in place, but they were not fully embedded or consistently followed by all staff. The provider engaged with local safeguarding systems however, had not always made prompt referrals to the local safeguarding team following incidents where people had been at risk of abuse.

Staff expressed they had awareness and understanding of abuse or neglect and knew what to do to make sure that people’s human rights were not breached or violated. However, staff did not always demonstrate a full understanding of their individual responsibility to respond to concerns about abuse when providing care and treatment, including timescales for action and the local arrangements for investigations. For example, we reviewed an incident of verbal and physical altercation between 2 people which had been reported to the local authority safeguarding team 5 weeks after the incident. The manager told us they were on annual leave when the incident happened, but the provider had arrangements in place to providemanagement oversight in their absence. However, the arrangements were ineffective, and external agencies were not notified of the incident. This was identified by the manager on their return when completing a monthly governance audit and an appropriate referral was made 5 weeks later. This meant timely external scrutiny had not always been possible to ensure people were safeguarded from abuse without unnecessary delay. People remained at risk of harm whilst opportunities to mitigate risks were delayed.

People and relatives felt the service provided by Trafalgar Care Home was not consistently safe. Comments included, “I don’t think they were keeping [my loved one] safe. [My loved one] got out of the home on [their] own. This incident was not explained” and “[My loved one] wandered out of [their] room at night and fell down the stairs. [They] did have an alarm mat, but the staff did not get to [my loved one] on time” and “[My loved one] is being kept safe but [they] never get out of bed.”

Where people lacked capacity to make their own decisions regarding where they wanted to live, we found appropriate legal authorisations for Deprivation of Liberty Safeguards (DoLS) were in place.

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 to people’s health, safety and welfare were identified. For example, risks associated with people’s mobility, swallowing difficulties and malnutrition. These risks were assessed before admission to the service and updated to as needed. Risk assessments were created and maintained within the provider’s electronic recording system, updated regularly and as things changed. However, people’s risk assessments did not always follow best practice guidance and did not always include clear guidance for staff on how to reduce or manage each risk. Staff did not always have the guidance necessary to keep people safe while at the same time supporting enablement and independence. For example, we reviewed a care plan for a person assessed to be at high risk of malnutrition. They had been assessed using the Malnutrition Universal Screening Tool (MUST), which is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition, or obese. We found contradictory information in different parts of their care plan which stated their MUST assessment scores were currently 2, 3 and 4.The person was no longer able to feed themselves independently and relied fully on staff assistance with all their food and drink. Some parts of the care plan stated this person had fluid restriction to 1 litre of fluid a day in place due to their health condition and instructed staff to monitor their food and fluid intake. Other parts of their care plan contained conflicting information that fluids were no longer restricted and to maintain normal hydration levels unless directed by a medical professional. The manager told inspectors food and fluid charts were used to monitor food and fluid intake for people with MUST scores 2 and above. There was evidence person’s food intake had been monitored with daily food chart. However, we found no fluid monitoring charts had been in place for this person. This meant people were at risk of not having their nutrition and hydration needs met, health deterioration and increased risk of some health conditions, such as malnutrition, osteoporosis, decreased muscle strength and lowered immunity.

We received mixed feedback from people and their relatives including people’s legal representatives about their involvement in creating and reviewing people’s care plans and risk assessments. People and their relatives did not always feel involved in managing risks, and risk assessments were not always person-centred, proportionate and reviewed regularly with people and / or their representatives.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, the premises were not always designed and adapted to meet all people’s needs. Leaders and staff did not always consider how environments can keep people safe from psychological harm as well as physical harm, for example in relation to sensory needs of people living with dementia.

Improvements were made by the provider on how to assess and reduce the risk of injury caused by people’s living environment since our last inspection. However, the signage, the decoration and other adaptations to the premises did not always meet people’s needs and did not always keep them safe. Design of the premises did not always support people’s independence and wellbeing. Adaptations made did not always meet the needs of the people who live there. For example, signage and orientation aids were minimal and further improvements were needed to help people orientate in their environment independently and reduce distress.

Effective arrangements were in place to monitor the safety of the premises, bringing in professionally qualified people to complete the necessary environmental and equipment checks. Staff were clear about their responsibilities regarding premises and equipment. Staff told us that they had received health and safety training and explained they would report any health and safety concerns to the manager or maintenance staff. Staff told us maintenance concerns were responded to in a timely manner. We observed staff using equipment correctly to meet statutory requirements and support people to stay safe. Relatives told us the building was old and decoration dated but commented on recent improvement, “It’s nice and warm now. The décor has been renewed. Some improvements have been done to rooms, carpets, lighting and air conditioning. The home looks better now than it did.”

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.

The manager used a dependency tool, and a review of people’s needs monthly or as and when needed to ensure good numbers and skill mix of staff and to meet people’s diverse needs effectively. They advised they were fully recruited into care posts and agency were not used to cover staff absences for over 6 months. Appropriate recruitment checks were carried out as standard practice. Recruitment processes were robust, and staff were recruited safely.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our SOFI, we observed people appeared calm and at ease while supported by staff. Staff knew people's non-verbal and behaviour cues, offering reassurance and distraction techniques to defuse escalating conflict between people.

There were enough competent staff on duty when we visited. Staff told us that they felt supported and received appropriate training to enable them to fulfil their roles. Staff support was given formally through supervisions, appraisals, and team meetings. In addition, there was support from senior staff working in the home every day. Most staff told us they thought there were enough staff on duty to support people's needs.

People told us staff were there for them when they needed, many indicating they could use their call bell alarm to summon staff support. People told us staff were skilled in the care they provided. We received mixed feedback from people, relatives and staff about staffing levels. Some feedback suggested there was a high staff turnover and staffing levels were lower than required. During this inspection we found no evidence there was a significant impact of staffing levels on people’s care and wellbeing.

The provider did not always effectively 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 provider did not follow national guidance in relation to infection control. Housekeeping staff maintained cleaning schedules of completed tasks, however these did not seem to reflect the environment. The premises the provider was responsible for were not clean or hygienic. This meant people were exposed to risks of acquiring and transmitting infections such as Covid, or Norovirus outbreaks leading to health deterioration.

At the last inspection we found that infection prevention and control measures were not being operated in the laundry. There were further concerns around the environment relating to the sluice room, malodours in communal areas and a person’s ensuite was used for storage of furniture and equipment impacting on effective cleaning. At this inspection we found the service to be generally clean, however the malodour in the communal areas was still present. Actions taken to address malodours were ineffective and did not ensure improvements to the environment, so it was. clean and free from odours that were offensive or unpleasant. This meant people had been exposed to infectious diseases and offensive and unpleasant odours, which had placed them at risk of deterioration of physical and mental health and wellbeing.

Relatives expressed their concerns about infection prevention and control practices in the service. Most relatives commented on strong and persistent malodours in communal areas. Comments included, “There is a strong [malodour] in some areas. It’s always been like that” and “There is a strong [malodour] in some of the communal areas. The combination of that smell and the smell of the lamb dinner made me feel ill.”

Staff received appropriate training on infection prevention and control (IPC) however they did not fully understand their responsibilities in relation to hygiene. The manager told us there was no housekeeping staff currently on the staff schedules over the weekends and surplus care staff were allocated to housekeeping duties. They told us they were currently recruiting to full time housekeeping position.

The provider mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning, including when changes happened.

People’s medicines were seen to be given in a safe and caring way. Medicines were administered in a timely manner and recorded on people’s medicines administration records (MAR). However, we found the provider’s medicine management policy had not always been followed, and there were still areas of medicines processes that needed to be improved. Personalised protocols were in place for all medicines prescribed ‘when required.’ People’s preferences about how they liked to take their medicines were considered and recorded in their care plans. However, they were not always effectively reviewed to reflect changes in people’s needs and preferences. For example, we reviewed records for a person who received all their medicines covertly. Their care and support plan did not mention covert administration. The manager arranged to immediately update the documents.

Audits and quality checks to ensure the proper and safe management of medicines were not always effective. For example, quality checks had not identified or addressed that the provider’s own medicines policy was not followed to manage the administration of covert medicines. People receiving their medicines covertly were not always safely supported in line with the Mental Capacity Act 2005. Not all people prescribed high risk anticoagulant medicines hadassociated risk assessments or 'flags' on their care record to indicate they were receiving blood thinners. This meant that staff may not be aware of the risks associated with this in the event of a fall or injury, and what they should be aware of to help prevent any harm. The manager took immediate actions to address this.

Medicines were ordered, stored at the correct temperature and disposed of securely. Medicines records showed that they were given as prescribed for people. We observed staff giving medicines safely and in a kind and caring way, taking time with people, and asking if any ‘when required’ medicines were required. We observed people’s individual preferences for how they liked to take their medicines were respected by staff. Medicines incidents or errors were reported and investigated.