Grove Park

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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

During our assessment of this key question, we found concerns around incidents affecting the health safety and welfare of service users which had not been reported, investigated or monitored, risks associated with use of equipment were not assessed robustly resulting in service users experiencing avoidable harm and management of people's medicines which resulted in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not protected from the risk of harm and abuse. Staff did not understand their responsibilities under safeguarding with respect to identifying potential abuse, escalation and the reporting of concerns. Bed rails and PRN medicines were in use without due consideration of this being the least restrictive or necessary option for the person. This resulted in a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not always supported by effective systems to ensure sufficient staff were deployed to meet peoples care and treatment needs in a timely manner or by staff who had training, skills and support in line with best practice. This resulted in a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

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.

People were not always kept safe. Staff and leaders had not promoted an open proactive culture to safety events. Incidents were not always reported or investigated this resulted in failures to learn lessons and continually embed good practice. People’s records contained images of bruising and skin tears which had not been fully investigated. This meant opportunities to improve practice to reduce harm had not been investigated or considered.

The registered manager and staff did not operate a proactive open approach to safety events and failed to provide assurance they monitored safety events effectively. The registered manager spoke of “Harm Free meetings” they had with staff. These meetings had not considered photographs of injuries or addressed shortfalls in reporting concerns or provide assurance lessons were learnt.

Providers processes had failed to identify shortfalls in staff practice and as a result injuries to people had not been fully investigated. The registered manager told us they relied on, “Staff completing incident reports.” Staff told us they took photos and reported concerns to the nurses. The registered manager and providers could not provide assurance incident reporting processes were robust or effective and as a result some people experienced avoidable harm. Following our assessment visit we sought urgent assurances from the provider of the actions they were taking to ensure people’s immediate safety and well-being. The provider carried out a full review of the incident reporting processes, reviewed risks to people and ensured concerns with staff practice were addressed.

People are not receiving a good standard of care. People’s needs are not met. People told us that staff were not proactive in seeking additional support for any health needs. One person said, “I was placed in the incorrect part of the home when I first came. I had people standing at the door of my room. One person even came in and drank some of my drink. Staff did come eventually when I pressed the call bell.” Another person told us, “I speak to staff about issues but nothing never gets done. I know who should help me and who to go to but nothing happens.” Another person said, “I was hoping to learn to walk again. Came here for help with rehab but it hasn’t materialised."

Staff were not confident that the registered manager was ensuring safe systems were being followed in respect to proving good quality and safe care. A recently appointed director of Grove Park set up their own investigation in response to concerns found at this assessment. It was found that management were not acting on concerns raised by staff and that staff felt people were being admitted to Grove Park with needs that couldn’t be met.

Feeback from professionals and partners was highlighted significant shortfalls on how staff and management worked together with them to provide consistent, effective care. One professional said, “General communication between ourselves and the home, unless there is a crisis / ongoing crisis is problematic - this has been an ongoing issue." Further feedback highlighted a possible language barrier between staff and professionals. This was an issue for management and were attempting to resolve. Another professional said,” I am aware this has caused frustrations for some relatives and residents who can't understand staff, due to difficulty deciphering accents. This is a management issue, not the fault of the carer / nurse.” Further feedback highlighted concerns around staff. Another professional said, “There has been issues with staffing in Grove Park, difficulties around having enough nursing staff on shift. There have also been occasions were the nursing staff on shift are junior in role and have less experience which makes things difficult when dealing with the complex nature of the residents.”

Systems to monitor care were not embedded to facilitate safe pathways and transfers for people. When people were admitted to the home, people had planned transitions to the home to ensure that they were comfortable and happy. However, this was not always the case. People told us that they were not happy and they would like to move home. Links with external agencies and professionals were not always effective. Systems were inconsistent and out of date which meant current and relevant information about people’s support was not always available. Senior staff linked with community nurses and the GP in weekly multi-disciplinary meetings to ensure that people were referred for appropriately health support. However, staff were not always prepared for these meetings, which meant appropriate referrals to mental health, for example were delayed.

People were not always kept safe from avoidable harm because staff failed to understand how to protect them from abuse. Following our initial assessment visit, we referred our concerns around unexplained injuries to commissioners and seven incidents were being considered through safeguarding processes. Managers and staff had failed to consider unexplained injuries within safeguarding processes. Furthermore, people were not always protected from the potential risk of inappropriate restraint. People were subject to blanket measures designed to keep them safe which were restrictive. The use of bedrails was prevalent within the service, risk assessments had not fully considered peoples safety or whether their use was in the person’s best interest. We raised our concern with the registered manager who told us for one person, “They shouldn’t have a bed rail, they are confused and could climb over”. People provided mixed feedback, one person told us, “On the whole I feel quite safe.”

The registered manager and staff were not clear on their safeguarding responsibilities. Statutory notifications had not always been submitted to CQC or the local authority alerted to potential safeguarding incidents. Staff demonstrated a lack of knowledge about safeguarding processes or when to escalate incidents. One staff member was unable to identify potential signs of abuse or who they would report concerns to. The registered manager was unable to provide assurance they had always reported allegations of abuse to the appropriate authority which resulted in a continued risk of harm. Following our assessment visit we sought urgent assurances of the actions they were taking to ensure people were safeguarded from harm. The provider took immediate action to investigate failures in managers and staff safeguarding awareness and responses.

We observed people with injuries that were explained, but we were not assured that the causes were sufficiently investigated to mitigate risks in the future. As a result of this, we found a further 7 people that needed to referred to local authority for safeguarding investigations.

Effective systems were not in operation to manage safeguarding risks. Following our assessment visits the provider has identified and reported further safeguarding risks which had not been considered or reported to the local authority. The provider could not be assured safeguarding training was effective. Records showed that staff compliance in safeguarding training was at 100% however, there was significant evidence managers and staff had not recognised or responded appropriately to abuse which had resulted in people experiencing avoidable harm. Systems had not always identified risks of inappropriate restraint. Risk assessments had failed to fully consider whether restrictions such as bed rails were in the persons best interest, least restrictive or being used appropriately by staff. One staff member spoke of changes which followed CQC raising concerns with the registered manager, “At nighttime the side rails are now down... we have to have more staff now as the residents have less safety. If we are busy, we cannot go to all residents... If they have dementia, they need side rails.” This comment was indicative of the risk of their use as a restrictive measure.

People did not always live safely and free from unwarranted restrictions. The service had not always assessed, monitored or managed safety well. People were not always involved in the managing of risk or supported by staff to take positive risks. One person told us, “The nurses had taken over my medication, I prefer to be independent with medicines”. We raised this with the registered manager who informed us they would arrange for a self -medication assessment to be completed.

Staff did not always process the skills and knowledge to work with people’s individual needs. One staff member spoke of their concerns managing some people’s complex needs, “[The registered manager] didn’t shy away from people who were difficult to place, … should not have taken [person]. It’s hard as they had nursing needs as well as mental health, I don’t know where else they should be. We have had a few where people said they shouldn’t be there.” Following our assessment visit, the provider took action in consultation with commissioners to review and reassess whether Grove Park Nursing Unit was the appropriate service to meet some people’s needs safely. They made arrangements for additional support and told us, “[Health professionals] are providing enhanced support to those with high behavioural needs until we find alternative placements”.

Staff knowledge around managing risks to people was inconsistent. For example, one person was risk assessed around their choices of where to sit and how to mobilise around the home. Some staff could tell us in detail about this person's risk assessment but others could not.

Risks to people were not always identified and managed appropriately. For example, guidance produced by the Alzheimer's Society advised that people living with dementia can find it difficult to communicate, which may result in the display of challenging behaviour. Staff should know how to recognise the signs for this and be proactive in their response. Care plans lacked information about people’s dementia and how this impacted on their behaviour and communication. Monitoring for specific triggers was not in place and there was a failure to ensure staff were provided with appropriate training and guidance. Specific triggers are unique to each person and can include restlessness and repetitive behaviours, the failure to monitor these increased the risks of people living with dementia not receiving appropriate support in a consistent and safe way.

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

People provided mixed feedback on whether there were enough staff to respond to calls in a timely manner. Their comments included, “Staff are good. No problems”, and “I think they are short staffed at times” and “I can have the bell going and see staff walk down, walk up and down again.” Records of call bell responses corroborated there were some delays in responding to peoples calls. Some had taken in the region of 40 minutes for the call bell to be answered. However, relatives spoke positively about the skills of the staff, one relative said, “I’ m very happy they clean everything. [Person] has repositioning and personal care support 4 hourly. If there's any wounds and blisters, they take photos”.

The registered manager did not always have clear oversight of staffing needs or staff skills and development. Records of call bell response times had not been regularly reviewed to monitor for trends or ensure people always received timely support. Staff members provided mixed feedback, “Everything is fine, earlier we had some staff shortage, now it is absolutely fine, we have enough now.” Another told us, “Sometimes not enough staff but they have recruited more staff.” Staff told us they had received a training both online and face to face. Records of training showed a high percentage of staff completion however, feedback from staff and records within care plans evidenced their lack of competency and skills. The registered manager spoke of challenges they had managing the induction of a number of new recruits. “They come from a very different background, some language challenges, cultural differences and a lot of work to do with (encouraging them to) speak up.”

We observed there were call bells ringing throughout the day. One person was ringing for at least 12 minutes before staff responded. This person had triggered a sensor mat alerting staff. Staff were engaging with people in a safe and positive manner.

The provider has not ensured managers and staff were monitoring staff response times and as a result some people did not receive timely support. Staff training and competency processes were not always effective. For example, medicines trained staff had completed competency assessments to check their understanding of legislation and guidance relating to schedule 2 medicines and their storage. The training and competency checks had not identified the significant concerns we found with staff medicines practice. Staff were consistently recruited through an effective recruitment process that ensured they were safe to work with people. New staff were expected to complete the care certificate. The care certificate is a set of standards for health and social care professionals, which gives everyone the confidence that workers have the same introductory skills, knowledge and behaviours to provide compassionate, safe and high-quality care and support.

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

People did not always receive PRN (medicine to be administered as needed) medicines safely or in line with good practice guidance. A number of people were prescribed PRN medicine for agitation. One person’s MAR recorded PRN for this medicine had been administered 43 times in one month. On a number of occasions, the medicine was administered without any corresponding entry for the reason it was given or the outcome for the person. This was not in accordance with National Institute for Clinical Excellence, (NICE) good practice guidance. Most people we spoke with gave mixed feedback regarding their experiences in respect of medicines. One person told us they wished to administer their own medicines. They said, “I would rather do my own medicines, feel like everything taken out of my hands. They keep medicines somewhere else and bring them to me.” The registered manager informed us they would arrange for a self -medication risk assessment to be completed to consider this person’s preferences. People spoke of their involvement with medicine reviews and changes. One person told us, “Yes, they are discussed with me, usually by the doctor and not the staff here. I am involved when the doctor comes.”

Staff we spoke with were unable to access detailed information or explain their processes for administering PRN medicine prescribed for agitation. We raised concerns with staff practice with the registered manager and subsequent to our assessment visits a staff member told us, “Medication has changed since you’ve been in, medicines have been scrutinised. We have been told to make sure everything is recorded. We know about documentation and medication; they are making a conscious effort to make sure everything is done right”. The provider was made aware of our concerns with regards to managing medicines safely and they took immediate action. They told us, “We have rebooked medicines management training and controlled drug training for all nurses. The [trained staff] meeting has been established where medication learning for medication and PRN will be discussed such as interval between dose and max dose. The controlled drug audit has moved to monthly.”

PRN protocols and care plans failed to provide guidance to staff on when it was appropriate to administer PRN medicine prescribed for agitation or any associated risks. Side effects could include drowsiness which might lead to an increased risk of falls. According to the British National Formulary (BNF) this medicine is usually prescribed as a short-term treatment and from records reviewed it is not evident that this had been regularly reviewed. There was a failure to guide staff to consider alternative and preventative strategies prior to administering this medicine. There was no information as to what the reassurance techniques could be used by staff to reduce anxiety and agitation in the person’s care plan or PRN protocol. A review of people’s daily notes evidenced that alternative strategies were not being considered prior to PRN medicines being given. Medicines were not always stored safely. We identified medicines, which required additional storage and administrative controls as per the providers policy, without any prescription label or records which left them open to potential misappropriation. The registered manager was unable to provide assurances these had been managed safely. A staff member spoke of how some medicines can come into the service without being formally checked in. Shortfalls in medicine administration processes potentially increased risks to people. There were significant shortfalls in staff medicine practices. For example, we found prescribed medicines which had prescription labels removed being kept in a box labelled “Homely Remedies”. A homely remedy is defined as a medicinal preparation used to treat minor ailments which does not require a prescription (NICE Managing medicines in care homes 2014). This increased the risk of people receiving medicines inappropriately. The staff did not carry out regular stock checks for medicines and records of audits were not available. We were not assured processes were robust.