Archived: The Grove - Care Home with Nursing Physical Disabilities

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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

The service was not safe or based around peoples needs. There was poor oversight and governance or learning from risk. Safeguarding concerns, accidents and incidents were poorly documented showing how these had been investigated so lessons could be learnt. We observed repeated medication errors which placed people at increased risk of avoidable harm.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People had experienced poor standards of care over a number of years due to inconsistent management and a lack of suitably qualified and competent nurses. This meant people were not safe, their clinical needs were not met, and the provider did not learn from its mistakes. We spoke with a number of people on the day of our two site visits. People were looking forwards to going out but there was a lack of daily structure.

During our site visit interim management arrangements had just been put in place so they had limited knowledge and oversight of people’s needs. The manager had just started the same day as our first site visit and already had plans for the weekend leaving the site with no clear management and oversight in place. Over reliance of agency nurses was a concern as all nurses spoken with were concerned about the level of nursing input people required and the time it took to complete key nursing tasks such as medicine administration. Nurses spoke of a lack of clinical support for them or oversight of clinical care. Nurses chose not to stay due to concerns about their professional registration and the concerns about the organisational structure and management of the home.

The clinical risk register had not been updated monthly or as required and key documentation was not up to date including fire risk assessments and peoples medicine records. This resulted in increased risks for people using the service as communication both verbal and written across the home was poor. The over reliance on agency nurses meant there was a lack of familiarity with the site, processes and people’s needs which meant if any given emergency situation mistakes could be made. There was a lack of accountability and oversight and a poor learning culture which would have enabled lessons to be learnt and steps taken to reduce the likelihood and severity of incidents.

People did not experience continuity of care when transferring from one setting to another particularly when going in to hospital because people did not have continuity of care and support and were not always supported by staff who had a good understanding of their needs. Care records were not always up to date resulting in infromation being possibly incorrect and poor handover procedures resulting in concerns from other agencies about the sharing of infromation. People were not able to tell us about their experiences of other services other that day care care which were positive.

Recent changes within the service meant there was no consistent management and there were concerns from other professionals about peoples care and support and poor management of people’s health care needs.

Staff and volunteers who were familiar with peoples needs helped ensure people had plans for the day and supported to attend appointments or have some social engagement. Continuity across shift was not robust and the whole staff team were no involved in handover and the dissemination of information was poor. Feedback from partner agencies were poor and the was a lack of continuity and oversight of peoples needs particularly when transferring between settings. The local Authority had been supporting the provider but improvements had not been sustained.

Resident of the day helped ensure care plans and risk assessments were reviewed. However, we found clinical oversight and communication was poor. Care plans reviewed contained contradictory information such as stating in one document no allergies in another stating they do have allergies meaning important information could be overlooked.

People's experiences had varied over time and their experiences varied depending on who was supporting them. Some people using the service had multiple needs including physical, health and additional communication needs and were largely reliant on staff to anticipate their needs. A regular turn over of staff , particularly nursing staff did not ensure people had continuity of support and barriers in communication led to fragmented care. People's communication plans were not in sufficient detail and their care records were not kept sufficiently up to date to ensure staff had the correct infromation at all times. We were not assured people were adequately safeguarded because care records were poor and when incidents had occurred these were not robustly documented.

We reviewed the safeguarding log and found leaders had not completed a full investigation into each safeguarding concern to ensure lessons were learnt and duty of candour was exercised. The current interim manager was familiar with systems and processes but was not yet familiar with the service or the people using the service so had not had the opportunity to audit records and identify missing information. For example where medicines had been administered inappropriately the safeguarding log said clinical supervisions had been held. However there was no record of this either in the service or within the human resources team. We were not assured that safeguards had been put in place to reduce the risk of further errors and ensure people received their medicines as perscribed. Staff had received safeguarding training through eLearning but oversight of staffs practice was poor and opportunities for staff to learn through experience and shared those expereinces were limited. Nurses in particular spoke of a lack of clinical supervision or managers they could refer to. Staff spoken with felt people were safe and protected from unnecessary risk. However there was a lack of consistent management oversight .

Observations of staff practice were poor with staff working in silos and not supporting each others. Mistakes had been made and there was evidence that staff did not challenge practice. Staff did raise concerns about management and oversight and roles and responsibilities were not clearly defined. There was not a strong focus on person centred care and practices within the home.

We reviewed the safeguarding log and corresponding information. This provided us very little details of actions taken to safeguard people and did not provide evidence of lessons learnt and duty of candour. We have since asked the local authority for all reported safeguarding to cross reference with our records to try and establish a more accurate picture of concerns.

Positive risk taking was encouraged for those who were able, but we found the necessary framework was not in place to ensure people understood the risks and all the necessary control measures were in place. There was also a lack of learning from incidents. People were observed as having the equipment they needed, and nurses delivered clinal care.

Risks were not properly managed within the service because staff told us there was no proper oversight or deployment of staff. We had concerns about fire safety and asked the interim manager who was on his first day to update the emergency fire evacuation plans, so they accurately reflected peoples room numbers. We asked the same of the electronic medication records. We also asked them to immediately ensure it was clear that there was a named person who would take control in the event of a fire or suspected fire. The clinical risk register was not up to date and peoples records were not updated following an incident to ensure control measures were in place and reduced the level of risk. The facilities manager confirmed they did not have a technical background and there was no maintenance person on site. This meant risks from the environment had not been properly eliminated. Individual room checks showed us that staff diligently checked people’s mattresses, bed rails and over equipment but we noted some equipment failures such as damaged bed rails which may not be resolved as urgently as we would like due to no internal maintenance service. The maintenance log demonstrated this.

Environmental risks were identified including a lack of window restrictors on all windows which included some of the first floor which some people had access too. The lift was still out of commission, and we noted other outstanding maintenance issues some of which would affect the upkeep and cleanliness of the home such as scuffed walls and skirting, ripped table clothes and evidence of water damage. Pipe work was exposed and was very hot under the radiator and staff confirmed that not all the radiators turned off. The medicines creams trolley was left with keys at the side of the trolley. We observed visible rust and wear on shower chair in one of the rooms and a build up of limescale residue on taps and in the shower area which could increase the risk of legionnaires disease . Food was left out on the side and doors to people's bedrooms left open and unlocked. Some people using the service were on specialists’ diets and at increased risk of choking if certain foods were consumed. We also noted other items harmful to health if swallowed left out such as nail varnish/ remover. Risks associated with poor mental health were poorly documented and risks from the environment not fully considered.

Whilst we did not identify any significant weight loss the monthly matrix did not give us an overview over a longer period of time for us to analyse weight trends. The monthly resident review identified several people who had lost some recent weight. The cook was unaware of this information so was not routinely fortifying food to increase calories to their food to reduce further risks associated with unintentional weight loss . We requested an analysis of accidents/ incidents and also looked at the safeguarding log. Neither gave us complete information about the concerns and actions identified to ensure learning took place to reduce the likelihood of further incidents. The oversight of risk was poor due to deployment of staff, but interim arrangements had been put in place and after our second day additional assurances were sought and extra nurses have been brought on shift to ensure peoples clinical needs were being met. Feedback from agency nurses on both days on site 03 and 06 June 2024 indicated nurses felt unable to complete clinical tasks in a timely way or safely. They all cited a lack of familiarity with the electronic medication system and the length of time it took to do peoples medicines. This potentially resulted in people not getting their medicines at the prescribed time or in line with their needs. Nurses said there was a lack of oversight and clinical support and several nurses said they would not return.

People had the equipment they needed and had the advantage of a lot of internal space. We had concerns about the external environment which may be hazardous to people using the service particularly those who could go out unrestricted. On the premises there was a large lake, and fish pond. The location was remote. Additional security checks had been implemented with door alarms fitted and checked every 15 minutes following a specific incident. However staff did not check doors regularly on the second day of our visit. Not all staff were aware of peoples movements. A check in /out board was not used effectively and when asking the interim operational manager peoples whereabouts they were reliant on activity staff having the information. Risk assessments for people going out independently were not particularly robust or reviewed adequately after incidents.

Care staff spoken with told us they felt people were safe. Nursing staff were concerned about meeting people’s clinical needs and the length of time it was taking to complete people’s medicines and cream administration. Nurses were not familiar with the electronic medication recording systems and were unable to scan in new medicines. They also raised concerns about fragmentation and lack of support for them as nurses.

Environmental risks were identified on the day of our site visit, and we were not assured that issues were dealt with promptly as there was no ongoing maintenance person on site. The facilities manager walked around and reported concerns but was not able to resolve them immediately and did not come from a technical background. From a previous audit we were made aware of problems with hot water not being available for a week. This had not been reported to CQC as required. We also identified an issue with regulating heat from the radiators with staff reporting one radiator did not turn off and there were exposed pipes increasing the risk of scalding. Control of Substances Hazardous to Health (COSHH) were managed to some degree with chemicals locked away including the laundry. However nutrient shakes, nail varnish/ and remover were accessible as were creams which were locked away but keys were accessible. A cupboard was also found to be unlocked with substances which could cause harm if ingested. The environment looked tired with scuffs to walls, floors, skirting boards and domestic staff stated they were not always fully staffed so it could be difficult to complete deep cleaning which was expected each day. When entering the kitchen area, we were not asked to wear aprons and there was insufficient oversight of infection control in this area. We also found rust on shower chair and rails, ceiling tiles with water damage and unlocked doors leading to rooms which had unprotected windows. One person’s record stated they had suicidal thoughts in the past and this was a concern given the risks identified from their immediate environment. The fire panel gave the incorrect number to call in an emergency and it was not obvious who were the fire marshals given that there were agency nurses and only one team leader as opposed to two. The emergency fire risk assessments correlated to the wrong rooms impeding speedy evacuation if there was a fire.

There was some daily oversight of cleanliness and maintenance of equipment as well as audits, but we found these were not effective due to the fragmentation and oversight on shift. For example, there were concerns about medicines running out or stocks of equipment such as syringes running low. We reviewed information relating to maintenance including the fire risk assessment which was satisfactory but had not been updated to include changes in staff. We also reviewed asbestos, gas and electrical reports which showed sufficient oversight. The lift servicing record was also in place, but the lift was still out of action. Immediate concerns were identified with medicines during our site visit 03 June 2024. A medication audit was carried out by the provider on 05 June 2024 , CQC carried out a second inspection on the 06 June 2024 with a medicines inspector and extensive concerns were identified with medicines practices.

People’s needs were met by a range of staff who provided activities across the day. Activity hours were included in the overall dependency tool and included both a volunteer who did 2.5 days a week and volunteer drivers. Support staff were employed in sufficient numbers to meet people’s day to day needs. Nursing hours were mainly filled with agency nurses which impacted on people’s experiences and safety as not all nurses were familiar with people’s needs. People did not benefit from consistent management and oversight which affected their expereinces and meant aspects of their care were not delivered effectively.

Activity staff and volunteers had created a good team who were able to provide people with some stability and social activity across the day and they felt people’s needs were being met. Agency nurses accounted for 70 percent of the nursing work force. They raised concerns about their wellbeing, the lack of structured breaks or support from higher management. Agency nurses were concerned about safety and described the service as chaotic. There had been no long-term management which had added to the staff’s sense of frustration and progression of the service. Relatives described management as coming and going and said they had noted the home going from full staff teams to reliant on agency staff but commented on limited impact on the care people received.

Throughout our observations we noted staff working hard and engaging with people. Plans for people to go out were dependent on staff being available and priority was given to health appointments. Staff were redeployed into other roles to account for last minute sickness. The cook was stretched as they were the only permanent member of staff and did not always have time to do home baking etc. The kitchen assistant’s role was covered by a member of the care team. Nursing staff were visibly stressed and frustrated by the length of time it was taking to do the medicines round and no one they could refer too to clarify issues. On our second day we noted the call bell went regularly and at times went into emergency mode. One person was becoming distressed and went outside and remained outside without staff supervision. Another person had a seizure and concerns were relayed about them not having their medicines on time. People's care and support was not centred around their needs.

Whilst the service had a recruitment drive and had assessed peoples dependency there was a lack of strategy to employ and retain a regular staff team who were familiar with peoples needs. Staff described themselves as feeling stretched and not getting their proper breaks or support required to be effective at work. Large number of management and nursing vacancies meant a heavy reliance of agency and temporary management arrangements which did not give permanent staff the structure and support they needed. Peoples dependencies fluctuated and this was not kept under careful consideration and review to ensure peoples needs could be met.

We did not ask people about infection control but noted people had spacious rooms which were clean and well organized with no visible smells. Daily cleaning records were available and showed peoples rooms were cleaned each day and floors were appropriate to peoples needs. We noted food and dirty dishes being left in peoples rooms which could increase the risks of cross infection.

Processes were in place to measure the day-to-day care people received including cleanliness and audits were in place to measure the effectiveness of processes put in place. We spoke to domestic staff who indicated they often ran short and found it difficult to keep up with the deep cleaning, particularly at times when there was only one of them on shift and they had laundry to cover. Gaps in recording were indicative of staff shortages and not enough consideration had been given to cover domestics holidays/ sickness. Domestic staff reported being tired and being asked to cover a very large home and pick up extra shifts.

The home appeared clean, but it was a very large building with lots of windows and frequently touched surfaces which would be difficult to keep clean without the right level of staffing. We noted a rusted shower chair, a build up on limescale on taps/ sink areas which could increase the risk of a build up of legionnaires bacteria. Tablecloths were ripped and there were a lot of floors, wall and skirting surfaces which were scuffed and or chipped making it more difficult to keep these areas clean. When entering the kitchen, we were concerned there were no aprons, and we were not asked to wear protective aprons etc. Surfaces/ flooring did not look particularly clean and there was broken equipment and a back log of washing up cups etc, some which were left in people’s room. By contrast the laundry room was very well organized. When we arrived at the service we were not asked to wash our hands or wear personal protective clothing despite the infection control policy stating visitors would be directed to wash their hands. One relative told us they had set up their own cleaning schedules for suction tubes used to clear their family members airways.

We reviewed cleaning schedules and the infection control policy which was up to date. It referred to guidance for visitors around infection control, but we were not asked to wash our hands or given any additional information. Audits were completed but some of the issues we had identfied had not been addressed.

People required support with their medicines. We were not assured people always received medicines on time or in line with their needs. This placed people at increased risk, particularly those living with epilepsy or allergies. Hospital admissions could have been avoided if people always received their medicines as intended.

Feedback from nursing staff was extensive. Nurses particularly agency staff felt the medicines round was unrealistic and time consuming. Nurses they felt under pressure to administer medicines, but this could take two nurses 2/3 hours at a time due to the complexities of the medicines administered, including the requirement to crush some medicines and administer through percutaneous endoscopic gastrostomy tubes ( PEG). Agency nurses told us their induction was not robust and they had limited awareness of the electronic medicines system used which took time and did not flag up time critical and or overdue medicines. On the first day of our site inspection agency nurses on their first day confirmed that peoples medicine profiles were not always linked to the correct room number which wasted time but also increased the risk of mistakes. Nurses were not familiar with where rescue medicines was stored or the complex medication regimes some people had although guidance was available. Care staff were taking people off site with their medicines, some to be administered at lunch time and had not received medicines training. This meant they might not be aware of how and why to administer medicines placing people at increased risk of harm.

We completed site visits on 3, 6 and 20 June 2024, on all days medicine administration to the length of the morning and into the afternoon. On the second day we noted a medication error was made, this was reported to the manager and the nurse tried to contact the GP but could not get through. There were concerns that no paperwork was completed at the time. Nurses were visibly stressed and on numerous occasions referred to our medicine’s inspector for advice. They told us they had no clinical support and were not familiar with people’s needs. We observed medicine keys for creams being left unattended on the side of the trolley which meant creams were left unsafely stored. We also observed creams out of date. We noted medicine fridges were recording the wrong temperatures over a number of consecutive days with no actions taken. This could make medicines less effective. We reviewed records on site and noted frequent entries about medicines not being available as required and other medical item stock running low such as syringes. There were entries stating medicines could not be added to the MAR sheet which meant there were delays in administering them. Audits had not been carried out regularly due to changes in senior management. By the second day of our inspection clinical audits had been undertaken but further medicine errors prompted a third day of inspection on 20 June 2024. The service continued to have issues around safety and competencies putting people at increased risk of avoidable harm.