Magnolia House Residential 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 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 people’s safe care and treatment and restrictive practices.

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.

Staff felt communication around learning from incidents was poor, for example one staff member told us, “Some incidents are discussed at handover or with staff individually, but I don’t think communication is always consistent. I think staff need to know about relevant incidents and any learning from them, so mistakes aren’t repeated.”

Due to ineffective systems in place to identify the concerns we found at this assessment; the provider was unable to identify and share learning with the staff team. The provider had also failed to report safety events to relevant external agencies, such as falls and pressure injuries.

The provider worked with people and healthcare partners to establish and maintain safe systems of care.

Healthcare professionals described a positive working relationship with the service and staff. Their comments included, “They are really responsive, they share information in a timely manner and are always open to take on board recommendations,” and “they work really well with other professionals and encourage involvement, they are open to support.”

The provider 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.

We found documented reportable incidents that were not notified to the relevant agencies, including CQC.

We saw evidence of restrictive practice including inappropriate use of a hoist and restricting access to mobility equipment.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Mental capacity assessments that were in place, were decision specific and followed the principles of MCA. However, we did identify some restrictions that did not have any best interest documentation in place. This placed people at risk of having restrictions in place without the legal framework to support these decisions.

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.

People told us other people entered their room against their wishes, one said, “I want it to stop. I find them lying asleep in my bed. I can’t lock it as if I fall down, I can’t be seen. It happens most days.”

People who had identified risks were not always supported to mitigate these. Additionally, we observed call bells were not always being left within people’s reach which posed a risk of them not always being able to call for help if required. People said, “I can’t always find it (on floor hidden under bed, moved it to in reach). If I ring, they’re sometimes not quick.”

Where people had identified risks, care plans did not always guide staff on how to support people at risk of infections for example, catheter care plan did not direct staff on how to identify signs of infection.

We fed this back to the provider who gave assurances they would address these concerns and update people’s care plans.

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.

We found there were some areas of the environment that could pose a risk of harm or injury to people. These included missing window restrictors and a damaged freezer. We fed this back to the provider who took prompt action to rectify these concerns.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

People and relatives provided mixed feedback regarding staffing levels. While some felt there were sufficient staff to meet people's needs, others expressed concerns that additional staffing was required, particularly during weekends and night shifts. A relative said, “In the evenings it can be a longer wait but they will always come in the end.

I’ll go and ask rather than rely on the bell. It can still be half an hour to wait as they’re busy. Heaven knows how long it takes when I’m not here to chase.”

Relatives also described a noticeable turnover of staff, which they felt may have impacted continuity of care and support. The competency of new staff was also questioned by one family, they said, “They have a high turnover, and I feel the information isn’t given to new staff while shadowing.”

Staff also felt it would be beneficial if there were more staff on each shift, for example a staff member said, “The staffing level is poor we are short staffed.” Another said staffing levels, “put pressure on staff and make it harder to respond as quickly as we should,” and “Nights can be particularly challenging because there are fewer staff available. If a resident becomes unwell, there isn’t always another senior or clinical person immediately available.”

We observed multiple occasions, and relatives and professionals fed back to us, that communal areas were often left unsupervised. Staff appeared to be task led within the vicinity or seen passing through and observing. A relative said, “They’re too busy clearing up to look at people properly.”

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.

People spoke positively about staff consistently wearing Personal Protective Equipment (PPE) and the cleanliness of the home. However, we identified a number of infection prevention and control (IPC) concerns within the service. This included damaged and deteriorating surfaces that could not be effectively cleaned, presenting a potential infection control risk. We also observed uncovered bathroom pull cords, which may be more difficult to clean and maintain. In addition, clinical waste bins were not available in all bathrooms and toilet areas, which did not support consistent IPC practices.

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

We found concerns with some elements of medicine management. These included topical creams not having open or expiry dates on them, protocols for medicines required as and when not having clear guidance for staff on when to administer and incomplete documentation relating to covert medicines. The provider assured us they would undertake a full review of all their medicines to identify and rectify any concerns, some of which were addressed on the day of the assessment.

People spoke positively about the support they received with their medicines, stating staff always waited by their side for them to swallow them and were offered pain relief if required.