Moorland Gardens 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 regulations in relation to safeguarding and safe care. Safeguarding concerns were not always identified and reported. The provider had not always ensured they managed safety risks to people.
 

This service scored 41 (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 a proactive culture of safety. We identified a large number of incidents where people had experienced emotional distress that had been unknown to the provider. This increased the risk of actions not being taken to mitigate future risks.

In response to the concerns identified, the provider took prompt action including staff meetings, retraining, and reviewing their governance arrangements.

The service did not always maintain safe systems to manage risks to people. The providers' systems were not always operated effectively, ensuring that people's health and safety needs were consistently assessed and monitored. During this inspection we identified incidents were not always known to the provider and safeguarding concerns had not always been reported.

However, records showed people were supported to attend appointments with external health professionals such as GPs and mental health services. A nurse told us, “If someone fell, we check for injury, do the observations and ring 999 or 111 depending on their condition.” A relative told us, “The care is very good. They use a hoist with two staff… I have no concerns about [Person’s] safety; [Person] has not had any falls.” Another relative said, “My loved one fell out of bed last week; we were informed straight away, and paramedics took them to hospital.”
 

People were not always protected from potential abuse. We identified in records incidents where people had experienced aggression from other people receiving care that had not been reported to the local authority safeguarding team. This meant there was an increased risk that people were not always proactively safeguarded from abuse.

In response to our findings, the provider reviewed their systems, records, submitted retrospective safeguarding referrals and provided further training to staff.

Staff we spoke with knew who they could report safeguarding concerns to. A staff member said, “I would whistle blow to the Local Authority, CQC or police if needed.”

The service did not always plan or deliver care in a way that ensured people’s needs were met safely. We found evidence staff had supported a person to move unsafely using lifting equipment while they were experiencing emotional distress. We also observed two occasions where staff used poor moving and positioning practices, placing people at risk of harm.

In response, the provider told us these concerns were addressed immediately with the staff involved through supervision. They also arranged refresher training, shadowing, competency checks and wider team training to promote consistent safe moving and positioning practice.

Care plans did not always contain accurate or consistent information about people’s health needs, for example, whether a person was living with diabetes. Following feedback provided at our second visit, there was evidence the provider had begun reviewing and updating care plans to improve their accuracy.

The provider did not ensure the environment was safe. During this inspection, we found areas of poor maintenance, including deteriorated walls, unsecured furniture, and missing or broken equipment. Fire doors across the service were ill-fitting or damaged, and some areas containing hazardous substances or hot water equipment were left unsecured. Window restrictors were not fitted with fittings in line with national guidance.

Following our findings, the provider took action such as clearing communal bathrooms, replacing fire doors, securing furniture, staff supervisions, environmental checks, and fitting window restrictors shortly after the inspection.
 

Although in response to our concerns the provider took action to retrain staff, we could not be assured staff had, prior to our inspection, received effective training or were always competent in meeting people’s needs safely. This included areas of incident recognition and reporting, safe moving and handling, medicines administration, infection prevention and control, and implementing accurate and consistent care plans.

However, we found staff were recruited safely and records showed they had received regular supervision. Overall, we observed there were enough staff deployed. A relative said, “I have no concerns about numbers of staff, there are plenty and they are the same faces.”

The provider did not always promote good infection prevention and control. We observed personal toiletries stored in the wrong bedrooms, creating a risk of cross contamination. Bathing facilities were used for storage, and there was no evidence that required water flushing was taking place, increasing the risk of poor IPC practice and legionella. We also observed ineffective cleaning. For example, bodily fluids were not removed promptly, ingrained dirt was present in sanitary areas, and several hand towel dispensers were damaged or unusable. Ripped furniture and areas of deterioration further hindered safe and effective cleaning. On the first day of our inspection, we observed the general waste bin was overflowing, when additional bins next to it appeared empty.
Following concerns identified during the inspection, the provider took immediate action, including removing personal items that posed a risk of cross contamination, addressing waste management, and undertaking cleaning and maintenance activities.

The provider did not always ensure the safe management of medicines. Protocols for medicines to be taken on an as required basis did not always contain clear or correct instructions. We observed poor medicines related practice, including pill crushers not being cleaned between uses, and topical medicines that were opened, undated, or had illegible labels. This meant people were at risk of not receiving their medicines safely.

Following observing concerns to topical medicines on the first day of our inspection, we signposted the provider to carrying out an audit in relation to this. As a result, topical medicines were removed and replaced. Medicines such as those in tablet and liquid form had been stored safely.