Cow Lees 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.

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 premises.

This service scored 59 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager explained the changes they had made since the previous inspection. They said they had to go back to basics and improve a lot including the culture. They felt they had improved and encouraged staff to take responsibilities and to reward and praise staff when required. The deputy manager said they investigated accidents and incidents for trends, we saw records that showed other aspects of the service were reviewed for trends and patterns. For example, they reviewed wounds, falls and complaints. One staff member said they had opportunities to review their practice by saying, “We think about it and share ideas and discuss it with senior staff and nurses.” They gave us an example for some people needing their towels warmed, to encourage them to have personal care. Clinical staff explained the process for reporting and recording accidents and incidents in the home. A member of clinical staff explained they were responsible for reviewing people’s risk assessments and care plans following adverse incidents to ensure any emerging risks were identified and plans implemented to keep people safe.

Staff confirmed learning from adverse incidents was shared in daily meetings and handovers between shifts. One clinical staff member said, “We have a huddle meeting every day and everything will be discussed there. We will pass it to care staff who complete any corrections or new decisions.”

The provider 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.

Staff told us nursing staff did regular blood tests and shared any relevant information with them, for example if they needed to look out for any changes in a person’s health and welfare. During our visit we saw a nurse communicating information to other health professionals appropriately, via the telephone in an office, respecting confidentiality. We saw a strong sense throughout conversations with staff that information was communicated across staff teams and to other professionals promptly. A nurse told us that when people needed to be admitted to hospital in an emergency, they sent people’s medicines records and a form detailing their personal preferences for the level of care they wished to receive (RESPECT form). The nurse told us there was no written process for sharing information about people’s risks and immediate needs, but people would always be accompanied by a staff member who would be able to share this information. The provider used a diary system to ensure people did not miss appointments with external healthcare professionals. Staff usually supported the same people to promote continuity in care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

People felt safe with the staff who cared for them. Relatives were positive about how their family members were treated. One person said, “I like it here. I have made friends here. My family visit me here and I feel safe here.” Relatives were confident in the actions taken by staff to ensure their family members were safe. One relative said, “I do think [Person] is safe here as they used to fall a lot, but they haven’t fallen since coming here.” Another relative said, “The staff are well trained. They are good at what they know what [Person] likes and doesn’t like. They look after [Person] and everyone else very well.” Staff knew what to do to protect people from poor practice. A staff member gave us an example of when they had noticed bruising to one person’s hand/arm. They were confident to inform senior staff who listened and looked into their concern. Another senior staff member said, “You would recognise if anyone was being abused through their behaviour, if they have bruising or are avoiding certain people. I have not seen anything like this. I would report to the manager, and they would do something about it.” There was accessible information and guidance for staff to remind them of their safeguarding responsibilities and how to report any 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.

Some people could demonstrate responses to situations which could place themselves or others at risk of harm. There were behaviour support care plans which informed staff as to any potential triggers for people’s distress or anxiety and the actions to take to distract and divert people to promote their emotional wellbeing. Care plans instructed staff to verbal de-escalation and distraction techniques and only use physical safety interventions as a last resort.

However, we were not assured all risks were considered and managed without limiting people’s freedoms. Whilst it was clear people needed support to safely access an enclosed external courtyard, staff told us they could only do this under staff supervision which meant nobody could freely go into the external courtyard for fresh air without asking staff first. When we asked 1 staff member if people could go into the courtyard independently, they responded, “No because the door is always locked. They can’t go out without a carer or a relative, nobody can go out on their own. If they are in the courtyard, they can’t go anywhere but they are not safe to go out on their own, they are always with someone. There are a lot of things out there like plant pots, chairs and tables. We like to have a carer with them just in case something does happen to them out there.” Staff assessed risks when people moved into the home. Staff completed an initial assessment of people’s risks upon admission to the home and developed a care plan to manage those risks. We found some risks within the home environment were not always checked effectively which exposed people to unnecessary harm. We have reported on those in safe environments.

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.

We found fire safety and health and safety checks had all been signed and checked as ‘Passed’ however fire safety issues that existed had not been correctly identified. For example, our observations in Cow Lees identified a number of concerns that had potential to compromise people’s safety. We found glazing to a window located on a staircase was broken and 1 person's bedroom that accessed the staircase did not close sufficiently to protect them in the event of a fire. The lack of effective safety measures with the increased source of oxygen had not been identified during any fire related checks. We found some fire doors closed too quickly which could potentially knock someone over whilst other fire doors closed too slowly or did not close tight on to the door frame. We saw 3 examples where fire doors to people’s bedrooms had been propped open which would have rendered them ineffective in the event of a fire. We found in Astley House, there was no emergency lighting above designated fire exit points and across all 3 buildings there were no monthly fire emergency light checks completed. This meant we could not be confident in the event of a fire emergency, emergency lighting above exits were in working order. We showed some of these concerns to the deputy manager who said in the emergency grab bag were torches that staff could use in an emergency. We checked a grab bag and there were no torches. This meant we were not confident fire safety measures in place helped keep people protected.

During our visit we saw a number of other safety concerns that had not been identified or addressed. We saw prescribed thickener located in an unlocked drawer in a communal dining room. If ingested, this had potential to cause a person harm. We found exposed pipework in a bathroom which people used, which also had 2 walking frames, and a hoist stored within it. We found free standing wardrobes were not secured to the wall in 3 bedrooms. Wardrobes falling over in care homes pose a significant safety risk to people, particularly those with mobility issues or cognitive impairments. To mitigate this danger, care homes should ensure all freestanding wardrobes are properly secured to walls.

We found some windows in people’s bedrooms and window restrictors may put people at risk. A number of people’s bedrooms had sash windows. One sash window had a damaged cord meaning the window did not stay open and dropped immediately. For others, if opened to their highest point, the window dropped quickly which could cause entrapment. We found windows did not have the correct window restrictors as described in Health and Safety guidance for care homes. We found some wooden windows and window sills were in a poor condition so we could not be confident the windows themselves would withstand the forces required, with or without restrictors. Radiators in some people’s rooms were not covered and in one example, the radiator was so hot it presented a scald risk if a person fell onto it. We found this radiator had a damaged valve which required a repair to lower the radiator temperature. None of these issues had been known or identified as a risk without us raising this to management. Before we left the premises, we were assured the radiator valve was repaired and the temperature had lowered.

We spoke with staff to see if they knew what to do in an emergency situation. A senior staff member said, “We have fire drills, they test the alarm each week. Residents go into the dining room; there’s half an hour burn through time on doors. You would vary where you take people depending on where the fire is. You would use a quilt and pillow to slide people if needed.” We discussed our concerns with the person responsible for health and safety at the home following our visit. They assured us action would be taken to review and make good any improvements they heard during our feedback or found themselves.

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.

Staff went through an interview process and references were taken up before they commenced employment. The provider completed appropriate and safe recruitment checks. Staff had 2 weeks induction, which included training in key areas to support them to provide good care. For example, in relation to safety interventions, food hygiene and manual handling. One staff member told us about their training and said, “It makes you ask is the battery working, is the wheelchair in working good working condition, before you start to help people.”

Overall, people and relatives felt there were enough trained staff. One relative said, “They (the staff) seem to have their finger on the pulse. There is no slacking off. They are always busy and they are very well-trained.” All staff spoken to said they felt there were enough staff to care for people. A care staff member told us there was never any delay in both staff being available, if a person required 2 staff to hoist. A senior staff member told us, “We have a lot of new staff. They're learning. The staffing levels are quite good.” We saw staff had enough time to support people, they were not rushed and there was always cover and support. Staff told us they were busy but staffing levels generally enabled them to maintain a presence in communal areas and provide the care outlined in people’s care plans. One staff member commented, “We are running from morning to evening and by the end of the shift, we will have finished everything.”

Staff received effective supervision to support their role and development. A relatively new member of staff told us they had received an induction when they started working at Cow Lees which had included face to face training and working alongside more experienced staff. This staff commented, “I got 3 weeks induction and training on mental health, dementia, safety intervention, moving and handling and fire safety.” Across all 3 buildings we observed appropriate staffing levels, in line with the provider’s planned numbers during our visit. Staff were observed meeting the needs of people and the registered manager said if staff levels needed to be increased, this would happen.

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.

Our observations showed improvements were required to make sure cross contamination and infection control risks were minimised. We saw cleaning mops were left in dirty water in mop buckets when they should be stored dry, upright. Overall, we found the home was mostly clean and tidy. However, we did identify some communal areas in the older part of the home were dusty and would have benefited from a deeper clean. Areas of woodwork were scuffed and chipped which made them difficult to clean effectively. In 1 person's bedroom their crash mat was dirty, and the inner foam was exposed which was an infection control risk. In another person’s bedroom we saw a hoist which was rusty and stained and people’s walking frames had been incorrectly stored in communal bathrooms. We observed in the laundry room there were 4 identical black bins. One staff working in the laundry room told us that bins were used to separate laundry into red bags for soiled items, peoples’ clothes, towels and sheets/slings. Staff had not labelled the bins, therefore there was a risk of the bins being used interchangeably which could pose an infection risk.

We did see some positive practices to minimise cross infection. A staff member explained every person has a minimum of two slings, “In case one is dirty and in the laundry.” A staff member confirmed care staff would undertake essential cleaning such as spills if domestic staff were not available and to keep on top of cleanliness. A senior staff member said they completed room inspections, however we found completed checks did not always identify issues. Handwashing signage was displayed in some toilet/bathroom areas and personal protective equipment stations were near bathrooms and were stocked.

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 reviewed medication charts and found medications were prescribed appropriately, and staff completed the medicines administration records (MAR) accurately. However, 2 people’s MAR included a topical cream to be applied. Staff wrote on the MAR to advise application of the cream would be recorded on the topical cream chart. We reviewed topical cream charts for the 2 people. Both included gaps and days where the cream was only recorded as being applied once.

One person had been prescribed laxative medicines with the following administration instructions: “1 - 4 sachets daily as needed”. This medicine had been given as a fixed dose only once a day for at least 2 months despite the person suffering from periods of constipation. We shared this with the management to make sure this person received the right support and access to other health services if required.

As and when medicine protocols sampled, included clinical guidance in terms of medicine to be administered, reason for administration, and maximum dose in 24 hours. Staff did use a document called ‘Carers Medication Notes’, but there was limited space to record the reason for administration, so tended to say “agitation” with no information to show other methods or interventions before a medicine was given. Good practice would be to attach the behaviour support plans to the PRN protocols to ensure these medicines were administered consistently and only as a last resort.

Medication was securely stored in line with best practice. Staff undertook fridge and ambient temperature checks to ensure medicines remained effective. Staff maintained a running total of medicines in stock following each medication round. This promoted good stock control and meant any discrepancies could be quickly identified. Paper MARs were used and they included photo ID and allergy details.

Some people were administered their medicines through a patch directly applied to their skin. There were processes in place to ensure patches were applied in accordance with manufacturer’s instructions and to maintain the health of people’s skin. Where people had medicines administered only once a week, medicines administration records were clearly marked with the day on which they should be given. Most people and relatives had no concerns with their medicines. One relative said, “He’s on [medicine name]. Their medication is reviewed all of the time and their meditation is done correctly. They ask my permission for everything even the Covid jab."