Moorleigh Nursing 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 regulation in relation to Safe care and tretment and premises and equipment.

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 had an engaging, proactive and positive culture of safety, based on openness and honesty and working with people to identify where areas could improve. Staff listened to concerns about safety and investigated and reported safety events. Lessons were continuously learnt to identify and embed good practice.

Staff and leaders demonstrated a positive learning culture. Incident and accident logs were updated, and there was clear evidence that lessons were learned from events. Staff spoke confidently about how learning was shared across the team, and people told us they felt safer as a result.

The provider worked well with people and healthcare partners to develop and maintain safe care systems where safety was actively monitored and managed. They ensured continuity of care, including during transitions between services. Transitions in and out of the service were well coordinated, supported by clear communication between staff and external professionals. People told us they felt reassured and well supported during these changes. One relative told us “[Person] has been there for a month and is settled. [They] are safe and staff are respectful. Staff carry out personal care [person] is clean and tidy. If they/we want anything it’s always done immediately’.”

The provider worked closely with people and healthcare partners to understand what safety meant to them and how best to achieve it. Staff focused on improving people’s lives while safeguarding their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately. Staff had completed relevant training and understood their responsibilities. Robust procedures were in place, and issues were reported and acted on without delay. People and relatives told us they felt safe and knew who to approach if they had concerns.

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 were assessed and appropriate mitigation strategies were in place; however, daily monitoring charts located in people’s rooms were not consistently completed. This created a potential risk, as discrepancies could arise between the recorded information and the care delivered.

Moving and handling risks were clearly identified, and appropriate equipment was readily available for trained staff to use. Staff told us, “There is good equipment and good training. We’ve had a lot of e‑learning and in‑house training.”

People also expressed confidence in the support provided, saying, “Yes, I need equipment to help me. Staff are on hand and know what they are doing.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. Although the registered manager had identified and reported many areas requiring refurbishment within the building such as damaged flooring, broken cupboards, leak in the conservatory, remedial works had not been undertaken by the provider. This left people at risk as of potential harm due to trip hazards and infection control, we also found that clutter was left in corridors such as discarded boxes. Slings and wheelchairs were left in communal areas. This was feedback at the end of the visit and immediate action was taken to remove clutter. It is important to note that the home was clean and free of any odour.

The provider used a recognised tool to ensure there were enough qualified, skilled, and experienced staff. Staff received effective support, supervision, and development opportunities. Recruitment processes were safe, and staff were deployed appropriately. Call bells were answered promptly, and people told us they rarely had to wait for assistance. There were mixed views about staffing levels. Some people felt there were enough staff and told us staff came quickly, whilst others felt that although staff were kind and caring they did not have enough time to spend talking to them. Relatives gave mixed feedback with some feeling that staffing was appropriate and others stating they felt more staff were required. Staff said they felt supported; however, staff told us that they did not always have enough time to spend quality time with people.

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. Personal Protective Equipment [PPE] was available and used correctly, and the home was clean throughout. Staff had completed relevant training and followed hygiene protocols. People told us they felt reassured by the cleanliness and staff practices. We did however find that 3 of the hand sanitiser dispensers were not in working order, when we asked a staff member if they had hand sanitiser available on their person, they confirmed that they did not. The Alcohol gel was also out of date on the upstairs and downstairs medicines trollies; these had expired in May 2023.

We also found that due to some areas requiring refurbishment although they were clean, they were not at an appropriate standard to ensure that infection prevention control was being managed as required.

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

On the day of the assessment, we found that prescribed medicines and medical appliances were not always stored safely. Lockable cream cabinets in people’s rooms were left unlocked with the key still in the lock, and thickeners were left out in communal areas rather than being securely stored as required.

Temperatures in the medication rooms were not being monitored as required. Sharps bins were overfilled and did not display the required date of opening. Medicines with a limited shelf life after opening did not consistently have an opening date recorded, meaning we could not be assured they remained safe to use.

We identified out-of-date medicines and medical devices stored alongside in‑use items, creating a risk they could be used in error. Not all emollients labelled “see topical chart” had a corresponding topical chart, and multiple emollients were in place for some people without clear indication of whether older products had been discontinued or returned. It was also unclear which body areas topical creams were prescribed for, and body maps were not always completed to guide safe administration.

Some dispensing labels were illegible. Information across medication documentation, such as medication administration records (MARs) and care plans, did not always match. There were no anticoagulant care plans in place despite these being high risk medicines, and one person’s Glucagen care plan lacked person‑ ‑centred which reflected a wider pattern across diabetic care plans.

Injection sites and patch rotation were not being managed in line with manufacturers’ guidance; for example, one person’s patch had remained in the same area for three weeks. Lorazepam was being administered to one person for anxious behaviours without evidence of non‑pharmacological interventions being attempted first.

We found examples where the required four hour interval between doses of time‑ sensitive‑ medicines was not consistently followed. Several MAR entries recorded multiple people’s medicines as administered at exactly the same time by the same staff member, which is not physically possible and raised concerns about accuracy of documentation. Specific times for medicines requiring administration before or after food were not always recorded.

Codes were being used on MARs without accompanying notes explaining why the medicine was given or what the outcome was. Medication stock checks were completed but did not always reflect actual stock levels.