Moorhead Rest 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

We identified breaches of legal regulations. The environment was not safe and risks to people were not managed well. Concerns relating to fire safety and infection prevention and control were identified. Reviews of incidents and accidents did not identify trends and themes and there were a number of issues identified with medicines management including administration and storage of medicines. Staff recruitment processes were not robust and not all staff had completed their required training. There was very limited information following safeguarding concerns to evidence lessons learnt was taking place. We found concerns in relation to staffing levels. A dependency tool was put in place during the assessment process.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the people we spoke to expressed that they felt safe living at this service, our assessment found elements of care did not meet the expected standards. On the first day of the assessment the lift was broken which meant some people had to stay in their bedrooms. One person who was at high risk of falls had no additional checks or equipment in place to alert staff they may need assistance. This meant people were at risk of harm as no additional measures had been implemented during a safety event.

Staff were knowledgeable about how to report accidents and incidents and told us what the process would be should someone have a fall. However, neither the manager nor the director could provide assurances around servicing for slings people used whilst using the hoist. Slings should be serviced regularly to ensure people are kept safe when using them. This meant people were using slings which may not have been safe to use. We found one sling which was being used was visibly frayed.

Accidents and incidents were recorded but it was not always clear what action had been taken following on from an incident. There was no detailed analysis in place to spot trends and themes to help reduce future incidents and evidence of lessons learnt was minimal. We saw evidence of people who take blood thinning medication had not had the appropriate medical attention following a fall. Audits of accidents and incidents were basic and did not identify concerns found during the assessment process.

While the relatives we spoke to felt staff acted on concerns, our assessment found elements of care did not meet the expected standards. This is because we found important information was not always passed on to the relevant teams.

Staff told us the manager informs them of when new people were coming into the service. One staff member said, “We get told by the senior or the manager (of new admissions).” The manager told us that pre-admission paperwork was completed by obtaining feedback from family members.

Partner’s felt improvements could be made in this area. Where partners had visited the service and created an action plan, they felt these actions were not always met in a timely manner.

Information relating to people’s initial assessments were not always fully completed and did not hold sufficient information to guide staff on how to safely care for people. Oral care plans were not always completed and, in some cases, had not been updated for several years. Although handovers were taking place, when an incident occurred, this was not always included in the handover records. This meant important information might have been overlooked and not shared with the appropriate staff or healthcare professionals.

People told us they felt safe. One person said, “I feel safe. I have not seen anything wrong, there’s been no trouble.” While people we spoke to felt safe living at this service, our assessment found elements of care did not meet the expected standards. Records were not robust enough to ensure risks of abuse were mitigated and there was minimal evidence to show what measures had been put in place when abuse was suspected.

Staff feedback in this area was mixed. Whilst some staff told us how they would spot signs of a person being abused, other staff told us they had not had training in this area. One staff member said, “I have not had training on how to spot the signs of abuse, but I have had training on what to do if I found a bruise.” Not all staff were aware of Deprivation Liberty Safeguards (DoLS) and what this meant in practice and the manager told us that DoLS paperwork was not up to date and relevant to people’s needs.

During our inspection we witnessed staff to be kind and people appeared to be relaxed around the staff team and in their environment. However, we found some equipment to be unsafe to use which could pose as a risk to people.

Processes to ensure people were protected from abuse and neglect were not robust. There was no clear evidence of internal investigations taking place or lessons learnt following an incident. Staff had not been trained in safeguarding and a recent safeguarding outcome report also showed staffed needed more training in this area. The safeguarding and whistleblowing policy was not detailed enough to guide staff on what to do should abuse be suspected. DoLS paperwork was not always up to date and a new referral hadn’t always been made when a person moved into the service. This meant people may have been deprived of their liberty without the appropriate safeguards to their human rights.

People’s views on managing risks were not always positive and not everyone had seen or been involved in their risk assessments. One relative said, “[person using the service] had a fall. Unsure if any risk assessments were done on returning home but they said [person using the service] is no longer mobile.”

Staff told us they were confident in supporting people when they experienced distressed reactions and that they had training in this area. Staff spoke about how they would report concerns to the manager and felt this would be acted on. One staff member said, “If I think people are not swallowing properly, I have told management, and they refer to the SALT (Speech and Language Therapy) Team.”

During our walk around we identified several risks to people including wheelchairs and walking frames cluttered in corridors posing a trip hazard to people. People in communal areas were left unattended for long periods of time with no staff presence. This meant staff would not be aware should someone fall, or if an incident occurred.

Risks were not managed well, and risk assessments were not always in place. Where they were in place, they were not always detailed enough to guide staff. One person who was prone to pressure sores did not have a skin care risk assessment in place. Mobility risk assessments did not always contain sufficient information for those who required a sling and hoist to mobilise, the risk assessment did not identify which type of sling to use, the size or which loops to use. Risk assessments relating to people’s specific health conditions were not in place, therefore, there was no guidance for staff should their condition deteriorate. Although we saw evidence of behavioural charts being completed, there were no risk assessments in place to guide staff on how to support people experiencing distress.

People told us they weren’t always happy in the environment they lived in. One person said, “The lift is broken all the time.” Whilst another person commented on their shower which often leaked. Another person told us, “There isn’t enough room here. The facilities are not really good enough, I could do with more space.”

Staff told us they hadn’t attended practical training such as fire drills and moving and handling and would find a practical course beneficial. Whilst most staff felt the environment was safe, staff raised concerns about how often the lift breaks down.

We identified numerous safety concerns. Window restrictors were not present, and wardrobes were not secured to the walls. In addition, cupboards were left open which contained electrical wiring and cleaning chemicals that can be dangerous to people. Cleaning products were also left out in communal areas and in people’s bedrooms. Although this was rectified during the assessment process, this posed a great safety risk for people living at this service. Fire escape doors were not secure and posed a risk to people and we identified numerous fire safety concerns. Doors leading to the garden were left unlocked, this led to a laundry room which again was unlocked and contained several hazardous chemicals. Again, this was rectified during the assessment process.

Staff were not carrying out checks on the environment and the management team lacked oversight in this area. The concerns found during our walk around should have been identified through provider checks and audits. There was an ongoing enforcement notice served by the fire service to improve the fire safety of this service and although some work had been completed, there was still outstanding work to be carried out to ensure people lived in safe environment. Some health and safety checks were being completed; however, this was inconsistent and various maintenance issues which we identified on day 1 of the inspection were still present on day 3.

People felt there was not always enough staff to respond to their needs. One person said, “There is not enough staff. We seem to be waiting ages. I have a call bell, but I rarely use it. They seem short staffed.” Relatives felt staff were suitably trained.

Staff told us they had an induction when they commenced employment and undertook training courses, however, they felt more practical courses were needed to further their knowledge. Staff felt there was not always enough staff, one staff member said, “There is not enough staff and not enough stimulation [for people living in the home] provided.” One person was using a hoist sling which was unsafe. The management team were unable to provide an additional staff member to mitigate the risks associated with unsafe equipment identified during the assessment. This meant we were not assured people were being cared for safely.

There were not always enough staff to monitor people. The dining room was left unattended for long periods of time whilst people ate their lunch, and the lounge areas were often left unattended. On one occasion, several members of staff were stood outside together whilst the lounge was unattended. There were not enough staff to sit and talk to people and quite often people were trying to alert staff of their needs but there was no staff presence.

Safe recruitment practices had not been followed. We identified several gaps in employment which had not been explored and a lack of references obtained. Disclosure and Barring Service (DBS) provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Several staff had convictions showing on their DBS records and no conversations had been held with them and the manager or director to ensure their capabilities of working with vulnerable people. Several staff had been promoted but not interviewed for their current role, this meant we could not be assured staff were working in the appropriate positions. Although some of the recruitment concerns were historical from the previous provider, no audit process had taken place to ensure staff were suitable for their roles and that the new provider was confident in their abilities. Staff were not receiving supervision that supported their learning and development, and training records indicated gaps in staff knowledge. There was no dependency tool in place so we could not be assured staffing levels were appropriate to meet people’s needs, however, this was put in place during the assessment process. There was no activity co-ordinator employed.

People were overall happy with the cleanliness of the home. One relative said, “It smells nice, and it is clean.” However, our assessment found elements of care did not meet the expected standards as we found several concerns in this area which would prevent good infection prevention and control practices.

Staff raised no concerns about the cleanliness of the service; however, some staff told us they had not completed training in this area. One staff member spoke positively of the directors as they had given them the opportunity to become an infection prevention and control champion.

Although the service appeared to be clean, we identified a number of concerns during our walk around. Chipped paint work was present throughout the home including doors and skirting boards and rusty items including toilet frames would prevent good infection prevention and control practices. Personal protective Equipment (PPE) was stored around the home and in people’s bedrooms. The PPE was left out of the original packaging, aprons were draped over towel rails and gloves were left out. Cleaning products and chemicals were left within people’s reach and the laundry room was open. The kitchen and the kitchen store contained items which were passed the best before date and in one case over a year passed the best before date and staff’s personal belongings were stored on the floor next to food products. Various foods/liquids that had been opened were not dated, therefore we could not be assured they were fresh and consumed within the set time frame. We also observed staff entering the kitchen area without the appropriate PPE.

Processes were not robust enough to ensure good infection prevention and control standards. Cleaning charts were not completed daily and there were no cleaning charts for the kitchen although they were implemented during the assessment process. Staff training compliance was poor in this area and the provider was not following their own policy.

Our assessment found elements of care did not meet the expected standards as we found several concerns in this area. People were prescribed medicines that needed to be taken at specific time intervals. Staff were not recording the timing of medicines, so we were not assured people were receiving their medicines as prescribed. There were other gaps in medicines administration records. We saw detailed information about why some people were prescribed paracetamol ‘when required’ (PRN Protocols). However, staff did not record whether the medicine was effective at relieving symptoms. Medicated creams, moisturisers and barrier creams to protect the skin were kept together, unlocked in people’s bedrooms without any risk assessment to ensure this was done safely. The temperature at which these creams were stored was not monitored. We found errors in peoples’ MAR charts. One person had been prescribed 28 antibiotic capsules, but we counted 30 signatures on their record. We also found an error in a dose of warfarin that was signed as given. Warfarin is an anticoagulant medicine and missing a dose or overdose could cause serious side effects.

The staff member who was administering medicines said they were unaware of national guidance on storing and administering medicines and staff were unaware of the need to obtain agreement from a person’s GP or other healthcare professional before administering homely remedy medication. This would ensure the medicine is safe to be given to people alongside their prescribed medicines.

Medicines were not being managed safely. We witnessed staff leave tablets in 2 people’s bedrooms for them to take later. There was no risk assessment in place to indicate this practice was safe. Fridge temperatures were not being recorded and the controlled drugs cabinet, which was stored in the kitchen, was often above the recommended temperature. This cabinet included medications such as morphine sulphate which becomes less effective when kept at warm temperatures. There was no medication trained staff on duty throughout the night, this meant we could not be assured people had access to medicines should they need it at night. Medicine audits were ineffective because they did not identify issues that we found during the assessment process or record actions to be taken to improve the management of medicines. The medication policy was reviewed in December 2023 but refers to regulations superseded by the Health and Social Care Act and outdated processes for ordering repeat prescriptions.