Archived: Stanholm Residential Care Home for the Elderly

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

The key question of safe was rated as good at our last inspection, however, at this assessment the rating had deteriorated to inadequate. We identified four breaches of the legal regulations. Staff did not protect people from abuse and improper treatment. They did not always identify allegations of abuse and make referrals in line with policy. Staff did not always assess risks to people’s health and safety or mitigate them where identified. Risk assessments were incomplete and did not include risks we identified during our assessment. People did not always have care plans to guide safe practice. Staff had not been recruited safely and had not received the training, supervision and checks to make sure they had the skills to meet people’s needs.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not an effective system in place to review and analyse incidents to ensure any actions or learning could be identified. Incidents and accidents, such as falls were recorded on a chart with a total. However, this had not been reviewed to see if any action needed to be taken such as referrals to the falls team. We identified one person had 4 falls since December 2023 with no action taken to mitigate the risk. There was no oversight of occurrences for anxious or distressed behaviours. One person could show feelings of being anxious and distressed, the registered manager told us this should be recorded by staff, however it had not. There was no system in place to identify any trends or potential causes.

People at risk had not benefitted from care plan reviews and management plans when they had fallen or their needs had changed. Learning had not been implemented following people falling or expressing distress or anxiety, people continued to be at risk.

Staff told us they record incidents and when people are agitated or distressed. Staff described how if one person becomes upset they reported this on the handheld electronic recorder and it would then be on the handover information for the next shift. Another member of staff told us, "We put it on the hand held and then tell the team leader, we do talk about the best way of managing things, sometimes its doesn’t work, it is what it is in the moment. We try to de-escalate some have had more experience than others." The registered manager told us, this process did not always take place.

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.

We observed safeguarding concerns and were not assured staff understood their role around safeguarding people they support. We observed a staff member used the 'drag lift' manoeuvre on a person. This move is referred to as an 'illegal move' as it can cause serious injury to the person. The other staff on duty did not challenge this behaviour.

People were not safeguarded from the risk of harm and/or abuse. The registered manager had failed to follow their safeguarding policy to ensure people were safe. The registered manager had not followed best practice as detailed in the Mental Capacity Act 2005, when deciding to place restrictions on a person. There were no records to show how the decision had been made and why they were in the person's best interests. The registered manager had not investigated or contacted the local authority when potential safeguarding concerns were reported by staff such as unexplained bruising.

Staff told us they understood what safeguarding was and how to report any safeguarding concerns. Staff told us, "I have no concerns regarding people, if I have a safeguarding concerns I report to team leader, if they don’t do anything I would report to (the manager). I would go to area manager or the safeguarding boards." Other staff were completing their training, one member of staff told us "I have done my E learning, but I am currently doing safeguarding".

People told us they felt safe living at the service and with staff. People commented, "Staff will come into my room to make sure I am ok”, “Staff support me to use my stand aid and will make sure I am comfortable”, “Staff are very helpful and kind” and “I feel very safe staff are there when I need them”.

People's health risks were not well managed. People who were at risk of falls did not have a robust care plan or risk assessment in place. One person's care plan contained contradictory information regarding their support with falls. Assessments of people's needs had been completed but these were not effective. One person had lost a large amount of weight over a year, their nutritional assessment had not identified the weight loss and no additional measures such as a fortified diet or referral to the dietician had been put in place. People's risk assessments did consistently identify all the risks and provide guidance for staff to mitigate the risk. People who are prescribed blood thinners were at risk of excessive bleeding if they fall, there was no guidance for staff about what action to take when this happened. Staff had not followed guidance following a fall, documentation stated observations should be completed for a period of time following a fall. Staff had not completed these, placing people at risk of not receiving prompt medical assistance, if needed. People who were diagnosed with epilepsy did not have a care or support plan in place to guide staff. Although the person had not had a seizure for many years, the person was still prescribed epilepsy medicines and no guidance was in place for staff should they have a seizure. When people were at risk of developing skin damage, people had not been provided with pressure relieving equipment to reduce the risk.

People told us they felt safe with staff and told us staff supported them while using their mobility aid such as a zimmer frame. People told us, staff made sure they were safe and comfortable when using equipment.

We observed one member of staff attending to someone who had an unwitnessed fall. They left the person alone, with out support under their head to go and alert another member of staff, they did not think to use the call bell or shout for assistance. We observed staff supporting people in unsafe ways such as 'drag lift' which placed people at risk of injury.

We were not assured staff understood people's health risk. Staff we spoke with did not know the risk to people around blood thinners. Staff described how they tried to manage people when they became distressed. "We have to try and distract. We put it on the hand held and then tell the team leader, we do talk about the best way of managing things, sometimes its doesn’t work, it is what it is in the moment. We try to de-escalate some have had more experience than others." Staff did not always know about potential risks to people's health and welfare. One staff member told us, "Some people do have blood thinners, I don’t deal with medication, I just do the personal care so I don’t know about that." Another member of staff told us they did not always know why changes had been made, one person had moved room and they had not been told why.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff told us they had not always received the training they required to meet people's needs including Parkinson's, which staff thought would be helpful. Staff told us they thought they needed another staff member in the afternoon. The registered manager told us they had requested extra staff from the provider which had not been provided.

People told us they may have to wait a little while to be supported. One person told us, "I generally have to wait a while I have spoken to the manager about this”. Another person told us, "Have had to wait if they are busy but not too long”, and "Do not have to wait long”. Another person told us, "we have some new staff and they're all lovely”. Relatives told us, “Staffing at weekends seem low, they have recruited”, another told us, “I would like to see the manager on the floor rather than in the office”.

Staff did not always have the training and competency to complete their roles. The training matrix evidence that some staff did not have the training they needed. Some people were living with Parkinson's disease, there was no guidance in place on how best to support them. Staff had not received specific training in supporting people with Parkinson's. One staff member was new to care. They had not completed their training in key areas including supporting people with moving and handling and safeguarding.

We observed there were not sufficient staff to meet people’s needs and keep people safe. Staff were rushed and had no time to spend with people. Some people sat alone in their rooms all day with minimal interaction. One person was described in their care plan as someone who enjoys being around other residents. They spent the day in their room periodically shouting out for support. People ate alone in their rooms. Staff told us these people preferred to be in their rooms and ate independently. We observed one person had dropped their fork and therefore resulted to eating with their hands. Some people had poor food and fluid intake, which may have increased if staff had time to sit and encourage them. There was no engagement for people to be involved in, no activities throughout the day.

Staff told us they were expected to clean as well as perform caring duties. "We have a lady who comes in 3 times a week, some people pick up on cleaning, We try and clean as well, best will in the well people need a wash first. I think we can do more cleaning quality." Another staff member told us, "I think its clean", and "The night staff do some of the cleaning like mopping and cleaning toilets if we are free in the day."

Some relatives told us they had some concerns about the cleanliness of the service. One relative told us, "Last time I went she was in room 6 the smell was terrible it wasn’t pleasant since then they have moved mum downstairs”. Another told us, "My first thought is a bad odour”, and "Residents have accidents, I have seen staff using dry clothes rather than a mop or disinfectant, I’ve witnessed that more than once”. Other relatives did not share these views and thought the service was clean. Comments include, "The service is always clean and tidy when I visit –it’s a lovely home a nice size in a nice location”, and “Always clean –they are well looked after, always well-presented when I see them both they always have clean clothes on”.

When we arrived at the service there was a strong odour of urine. We walked around the building there were people in the lounge ,we observed 2 mop buckets in the lounge full of dirty water. There were chairs in the lounge which were very dirty.

There were no effective systems in place to make sure the service is clean. There was limited domestic staff available, there was one cleaner employed who worked 3 days a week. The other days of the week staff were expected to clean the service as well as their caring duties.

People told us they were happy with staff giving them medication and received medication when they needed it. One person told us, "Oh yes, I always have my medication on time and know what my medication is for I have Paracetamol 4 times a day and if I needed more staff would have to check with the Doctor”. Another told us, "Staff come in and give me my medication, they will explain what it is for “ and "They give me my medication”.

There were processes in place to ensure people received their medicines safely however, these were not always effective. People’s medicines had been unavailable or not administered as per the prescribers’ instructions. One person had been administered an expired medicine. Where people were prescribed medicines that required extra safety monitoring, these had not been risk assessed. When people were prescribed blood thinners there were no risk assessments in place for increased risks of bleeding and bruising. Staff had not ensured people’s medicines were available when they needed them, this meant people were at risk of their health conditions being poorly managed. Staff were not completing regular audits or ensuring medicines were suitable for use which had resulted in 1 person being administered and out of date medicine. Staff were completing regular temperature checks, however; the fridge maximum fridge temperature had been recorded as 19.8 degree’s for several months, but no action had been taken. Care plans were not person centred and did not contain information to support staff to manage people’s health conditions. There were no care plans in place for people diagnosed with epilepsy. Staff did not follow current infection control guidelines regarding hand sanitising when administering medicines.

Staff told us they were using a new electronic medicines administration system. The registered manager did not know how to carry out an audit using the new system and no audits had been completed since November 2023. Staff were not up to date with people’s care needs and were not able to identify people with specific conditions such as epilepsy and diabetes. Medicines were not stored in a suitable way. Staff told us they did not have any extra storage for excess medicines. Staff did not know people well and were not able to identify those people with people with specific health conditions such as epilepsy and diabetes.