OLIVE ROW CARE HOME

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• 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

Staff did not consistently protect people from abuse and improper treatment. They did not always identify allegations of abuse or make referrals in line with the providers policy and procedures. Risks to people's health and safety was not always assessed or mitigated. Equipment designed to support peoples’ needs and to keep people safe was not always being used appropriately. People received care from staff that had not received the training and supervision required to carry out their role. People were at risk of having un diagnosed infections or contracting an infection from others. People did not consistently receive their prescribed medicines. The provider failed to have reliable systems in place to manage people’s medicines safely or in accordance with current legislation and guidance.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people we spoke with told us they felt safe, however, one person told the inspector of an incident which occurred when staff was supporting them to move in bed. The inspector informed the management team of this on the first day of the assessment who advised they would investigate. This was followed up by the inspector on the second and third day of the on-site assessment and found that the management team had not followed safeguarding procedures including reporting the alleged incident to the local authority safeguarding team. We could not be assured that staff and the management team would recognise safeguarding concerns and take the appropriate action to protect people from potential harm.

Staff told us they had received training in safeguarding but did not feel confident in recording incidents. Staff had not received the training they required to report or record incidents and accidents. We were not assured staff understood safeguarding or when to take appropriate actions. Where the manager was made aware of incidents, they had carried out investigations but failed to report these incidents to the safeguarding team. People were at risk of harm as staff did not recognise when or how to record and report incidents.

Where people were experiencing distress and tried to express their concerns with staff, staff responded politely, however, they did not address this distress or take action. We observed people asking to be moved from the dining area after lunch but staff ignored their requests, this created conflict and frustration leading to an incident. Staff failed to record the incident accurately, therefore, this could not be reviewed by the management team to take appropriate action and reduce the chance of it happening again. People had body maps in their rooms which detailed the condition of their skin from 11 March 2024. These body maps showed people had unexplained bruises to their bodies of differing ages as described as blue, green or yellow, denoting the age of the bruise. The accident and incidents recorded did not correlate with the bruising reported on the body maps. For example, one person had extensive purple bruising and a dressing to one arm. There was no incident or investigation recorded relating to how they had incurred these injuries, or any evidence of a medical review.

There was no reliable system of recording incidents or unexplained injuries. Staff failed to record all incidents, and where they did, the management team failed to follow the provider’s safeguarding processes as they did not report incidents or unexplained injuries to the safeguarding team. Records relating to mental capacity assessments were not always complete and where mental capacity assessments had identified people lacked capacity, best interest decisions had not been completed in consultation with people's relatives and/or representatives. Systems and processes had failed to identify this.

People who had been identified as at high risk of falls had sensor mats to alert staff when they started to mobilise to reduce their risk. However, the sensor mats were not always switched on or in the right position. People remained at high risk of falls as staff had not ensured measures to reduce risk had been taken. People at risk of constipation did not have their bowels monitored to detect constipation. Although staff recorded when people had their bowels open, there was no clinical oversight to understand when people required medicines or medical advice. For example, records showed one person had not had their bowels opened for 13 days or had regular laxatives during that period; they were experiencing symptoms of constipation and medical advice had not been sought. People who were cared for in bed or in wheelchairs were in the same position for prolonged periods of time. Staff recorded when people were assisted to change their position to relieve their pressure areas, however, some nights staff did not record any repositioning. One person had a notice in their room stating they needed their pressure relieving mattress to be set at 68Kg, but their mattress was actually set at 95Kg. This placed people at higher risk of acquiring pressure ulcers and worsening of existing pressure ulcers.

The manager was aware people’s risk assessments and care plans did not reflect peoples’ current needs. The care plans did not provide enough detail to inform staff how to meet people’s needs. The manager was in the process of updating peoples’ care records, but they told us it was “going to take a considerable period of time.” Staff did not have the information they required to know how to manage conditions such as chronic obstructive airways disease, mixed dementia, autism, diabetes, falls or high infection risks.

People who were in communal areas were not always supervised. One visitor told us the person they had come to visit had been admitted to the home due to not eating and falling. This person had missed their lunchtime meal due to staff error and was then left for long periods in the lounge without supervision. This person was at increased risk of harm from falls due to lack of food and supervision.

There was no system in place to ensure people’s risks were assessed or reviewed as their needs changed. There was no system to ensure staff had all the information they needed to provide care that met people’s needs.

Equipment designed to support peoples’ needs keep people safe was not always being used appropriately. For example, one person was seen in bed and they had not been able to get out of bed for a considerable length of time due to their wheelchair being broken. The person was at high risk of pressure ulcers and deterioration in health due to the risks of being cared for in bed. Although the new manager had identified this and had contacted a local repair company, the wheelchair remained unusable.

The management team and staff had not identified where equipment and furniture may cause harm to people. For example, one person had a bed extension in place, but staff had placed the extended mattress in the bed incorrectly which meant the person’s feet were resting against the upturned mattress, placing them at increased risk of pressure damage to their feet. Following feedback from the inspector, the bed extension was removed. The manager and staff had not recognised the armchairs in communal areas were too low for people to get out of unaided; they had not involved health professionals such as an occupational therapist to assess people’s independence with their mobility.

During our assessment, we found aspects of the service environment, equipment and furniture that increased the risk of harm to people. We observed people living with dementia opening cupboards which had thickening powder stored inside. This powder is used as a thickening agent for people with swallowing difficulties. This placed people at risk of harm if ingested. We also found other cupboards and rooms within the home that stored substances hazardous to health, such as cleaning products, that were accessible and unsecured. This increased the risk of harm to people if used or ingested. The communal areas had armchairs that were too low for people to get out of unaided. People struggled to stand up from their armchairs and required additional assistance from staff. Staff were seen to not always use safe moving and handling to get people from sitting to standing as they pulled on people’s arms. The home had under floor heating and radiators which kept the home very hot. People only had a thin sheet or thin cover as their bedding; people told us this was because their rooms were very hot. The manager told us they were exploring what they could do to turn the heating down; they were purchasing thermometers so they could monitor the temperature in peoples’ rooms.

The management team and provider failed to have sufficient systems to check equipment was in good repair, and installed correctly or to ensure substances that were harmful to health were locked away when not in use.

Although there was enough staff on shift, people and their relatives told us of their experiences when requesting support from staff. A person told us, “I want to go to the toilet in there (pointing to their en- suite). They [staff] came and said ‘I will get a hoist’, they never came back, then another [staff] came and I said it again, they never came back, until one came later and they got me out.” Relatives told us staff did not always respond to people’s call bells in a timely manner. A relative said, “I have heard the bell going and going and have been to see [people] as it’s been going so long time. I have been in and asked the staff to change [person’s] pads as they have been wet, and they say they would be a minute, but they come 40 minutes later. Sometimes they are very slow.” Another relative told us, “They [staff] are not well trained. [Person] is stuck in her room, and she says they [staff] do not come when she calls the bell, they say they will be back in a minute but its normally 10 minutes. The other day the person’s buzzer next door was going, and I went to answer it, it was going that long.” People received care from staff that had not received the training and supervision required to carry out their role. One person said, “Some know how to wash and dress me, some don’t, but they are all being trained.”

Staff told us they would like more training. They said “Support with challenging behaviour could be better. Staff get hit, scratched almost every day.” At our last inspection on 1 February 2024, the staff trainer told us staff had received the training, but this had not been embedded or their competencies and understanding checked. They described how staff had not shadowed experienced and skilled staff. The acting manager and trainer told us they were concerned with the poor personal care and moving and handling skills. The trainer was allocated to the home to provide training. At this assessment, we found the trainer had been allocated to the home for only 2 days a week. Training records showed between 12 and 29 February 2024, 12 senior care staff and care staff had received training and had their competencies checked. This meant 58% of care staff and 71% of senior care staff had not had the training or their competencies checked to ensure they had the skills and knowledge to provide pressure area care that meets service users’ needs. The provider had failed to implement sufficient training, supervision and competency checking to ensure all staff had the skills, knowledge and competence to provide safe care.

There were appropriate staffing levels within the home, however, the provider had not ensured there was the right staff skill mix to make sure people receive consistently safe, good quality care that meets people’s needs. All staff spoke with people politely and appeared to be kind. However, they did not understand how to meet people’s needs. For example, when people became anxious and were asking for assistance, staff did not understand, this caused people to become upset and angry. This meant situations escalated and staff were subject to verbal and physical abuse.

The provider had failed to implement sufficient training, supervision and competency checking to ensure all staff had the skills, knowledge and competence to provide safe care. Training records showed not all staff had received the training they needed to provide safe care. There was no system of ensuring every member of untrained staff was supervised or that trained staff were providing care in line with the training they had received. There was no process in place to check the on-going registration status of nurses or agency nurses. This is important to ensure nurses have no restrictions or cautions and their registration is up to date.

People and their relatives gave mixed feedback regarding the cleanliness of the home. One relative said, “It’s not clean and it smells.” People told us the cleaning staff cleaned their rooms every day. A person told us, “The [cleaner] comes in every day, far more than they used to.” People told us they were offered showers but then staff did not come back to assist them. During the assessment, the inspector reviewed care records which showed eight people had experienced episodes of diarrhoea over a period of 4 days. Staff had not reported this to the nurses or management team, which placed other people at risk of contracting diarrhoea. People who had urinary catheters were at risk of infection due to the lack of accurate monitoring of their fluid intake, the measuring of their urine output and consistent timely changes of their catheters and catheter bags. One person had been admitted to hospital with a urine infection after staff failed to replace their catheter at the prescribed time.

Staff were not skilled or experienced enough to understand when people’s behaviour or appearance could indicate infection or ill health and therefore, did not report any changes. This meant that people were at risk of having undiagnosed infections or contracting an infection from others who had skin or bowel infections. Where people’s behaviour or appearances had changed, staff failed to investigate or take people’s clinical observations in a timely way to check their health and welfare or refer people to the appropriate healthcare professionals.

We observed three people in their bedrooms who appeared unwell and staff had not taken any action to identify the cause of their presentation. Two of these people were experiencing symptoms of diarrhoea. We brought this to the attention of staff who told us that other people within the service were also experiencing these symptoms. Staff had not raised this with the senior staff to ensure measures were put in place to prevent the spread potential infection. The home appeared clean. The bathrooms were well equipped but appeared unused, as people received personal care support in their bed or chairs.

There was no reliable system or process in place to ensure people’s catheters and catheter bags were changed at prescribed times, or to ensure all people with catheters had their fluid intake and output monitored and actions taken when too low. There was no reliable system to identify the potential of an outbreak of diarrhoea or other infections in a timely way. The audits for infection control and prevention were not always completed or had actions that corresponded to the issues identified. Where spot checks had been carried out for staff using personal protection equipment and had washing, these records were incomplete. This meant there was not a comprehensive oversight of the infection control and prevention within the home, placing people at increased risk of acquiring an infection.

People did not consistently receive their topical medicines. One person told us, “I have very dry skin, staff are supposed to put cream on, but they can’t always find it.” People did not consistently receive their prescribed medicines. For example, one person did not always receive their prescribed medicine in the evenings for the treatment of diabetes. This meant the person’s blood glucose levels were too high in the mornings. This placed the person at increased risk of health deterioration. People were not assessed for their level of pain, or receive regular pain relief when they had known conditions that cause pain. People did not receive their medicines if they were asleep in the morning; staff did not administer their medicines later in the morning when they were awake. People were at risk of increasing symptoms of their long-term medical conditions.

Staff did not always ensure the door to the medicines room was locked when unattended. Staff did not record the times they administered time-critical medicines; there was no assurance people had received these medicines on time. This made it difficult for health professionals to make an informed assessment when called upon to review increasing symptoms. Staff did not always know why people were on their medicines or how to give them. For example, one person was prescribed an Epi-pen for the treatment of allergic reactions but when questioned by the inspector, none of the staff knew what the person was allergic to or how to give the injection. Staff did not always check if people required laxatives. This meant people did not always receive their laxatives when they needed them, leading them to have constipation.

The provider failed to have reliable systems in place to manage people’s medicines safely or in accordance with current legislation and guidance. There was a lack of clinical and managerial oversight of the administration of medicines. Staff had not always recorded they had administered prescribed medicines, and there was no on-going stock count to check whether this was a recording error, or people had not received their medicines. The providers systems and processes had not identified this. People were not referred to health professionals in a timely way when they regularly refused their nighttime medicines. People were at risk of increasing symptoms of their long-term medical conditions. The providers systems and processes had not identified this.