Roseside

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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

Breaches of regulations in respect of safe care and treatment, medicines and safeguarding were found under this key question.

The management of medicines was unsafe. A significant number of people had not always received the medicines they needed. Some people had not been given their medicines in a safe way in accordance with the prescriber’s instructions and records in relation to the application of prescribed creams and thickening agents in people’s drinks were not accurate. There was also a lack of clear protocols for the administration of ‘as and when’ required medicines such as painkillers. This increased the risk of people’s physical and medical conditions not being properly treated.

Care plans were not always accurate or sufficient and did not always contain consistent or enough information to guide staff on how to mitigate risks. Not all of people’s needs were properly assessed. For example, people’s medical, clinical and mental health needs. As a result, staff lacked clear guidance on how to support people safely. We found serious shortfalls in diabetes and PEG (Percutaneous Endoscopic Gastrostomy) management, nutritional care, continence and bowel management. Some people experienced increased intrusive checks and restrictions on their day to day lives, without appropriate authorisation in accordance with Deprivation of Liberty Safeguarding legislation (DOLs). These practices failed to protect people’s human rights and placed them at risk of improper treatment. Concerns about the use of restrictive interventions were reported to the Local Authority by CQC.

There were processes in place to support a learning culture, but these were not consistently, or effectively applied across the service. Staff told us learning was shared but records did not reflect this. Staff were recruited safely. There were enough staff on duty to meet people’s needs. Staff were trained and told us they liked working at the home. The home was clean and well maintained.

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.

People’s accident and incident records showed appropriate action was taken to protect the person from immediate harm at the time of the incident. It was unclear from the records kept what lessons were learnt and implemented to improve people’s experience of safe care in the longer term.

Staff told us daily handover meetings took place at the start of each shift to share updates on people’s care. They told us a ‘huddle’ meeting also took place each day were any lessons learned from accident and incidents were shared. We found however that the minutes from these meetings did not reflect the sharing of any learning or best practice.

There were processes in place to support a learning culture, but these were not consistently, or effectively applied across the service. Records did not reflect that learning from accident and incidents, or recommended best practice was routinely shared at staff meetings.

Accident and incident records for some people showed a repetitive cycle of incidents that suggested the action taken to prevent them from happening again was not effective.

Where service improvements or recommendations were made, either internally or externally by the Local Authority, there was limited evidence these had been shared with the staff team and implemented appropriately. For example, a recent visit by the Local Authority identified improvements were needed in care planning, record keeping and the mental capacity, best interest process. During our inspection we found effective action had not been taken to improve these areas.

People’s needs were not always fully assessed, or accurately described to promote a safe and positive transition to other services, should this be required.

The care records of four people with complex needs were reviewed during the assessment. We found the needs and risks of these four people had not been fully assessed, or accurately described to promote a safe and positive transition to other services should this be required. Some hospital passports designed to ensure a safe transfer to hospital contained inconsistent information or had not been properly updated when people’s needs had changed. Furthermore, people’s known risks were not always clearly identified and available for health and social care professionals to be aware of when planning care and treatment.

The manager told us referrals to the service came via a central admissions team. A pre-admission assessment was then completed to ensure the person’s needs could be met by the service prior to their admission being accepted.

We identified after admission, ongoing assessments and care planning of people's needs was not undertaken effectively in order to plan people's care and identify associated risks in order to effectively plan people’s care and reduce any associated risks.

The Local Authority told us that the provider was due to move to an electronic care planning system, but this process had been delayed. A Local Authority Quality Assurance visit had identified shortfalls in the consistency and accuracy of care planning information.

There were processes in place to promote safe systems, pathways and transitions but they were not used effectively to ensure positive outcomes.

Assessment and care planning processes were not always thorough or consistent. People’s medical and physical health conditions were not properly assessed or described and information in people’s care plans was not always been properly updated when their needs changed. This meant incorrect or out of date information may be shared with other medical and health and social care professionals involved in the person’s care.

People we spoke with told us they felt safe. We found however that some people’s rights and freedoms were not adequately protected. Some people experienced increased intrusive checks and restrictions without appropriate authorisation in accordance with Deprivation of Liberty Safeguarding legislation.

Staff also lacked clear guidance on how to safely and appropriately identify and respond to signs of distress. This meant, at times, people may have experienced physical restraint to control their movements and behaviours, which may have been avoidable had suitable positive behaviour support plans been in place.

Concerns about the use of restrictive interventions was reported to the Local Authority by CQC during the inspection. The Local Authority confirmed a review into these practices was commenced.

Some people and staff experienced repeated verbal or physical abuse from other people living in the home. There was no evidence that any learning was shared from these events to help prevent them from re-occurring.

Staff members told us they had completed safeguarding training and had regular updates. Staff knew what action to take should they suspect or witness potential abuse.

We found however that the provider and manager lacked adequate knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty (DOLs) frameworks to ensure people were not subjected to intrusive and degrading treatment that did not meet their needs and preferences. The Local Authority were not always informed of the potential use of restraint and the use of restraint had not always been included in DOLs applications submitted to and approved by the Local Authority. This increased the risk of these additional restrictions being unlawful.

During our visit, interactions between staff and people living in the home were kind and respectful. However, we observed that one person required the supervision of a staff member at all times. We saw that this person was not supported in the least restrictive and intrusive way as possible in accordance with their care plan.

We found that another person’s clothes were locked in a cupboard outside of their bedroom. There was no evidence the decision to remove this person’s clothes from their possession had been consented to, by them or subject to a mental capacity process if the person lacked capacity to consent.

Organisational shortfalls in compliance with the MCA and DOLs legislation were not identified by the processes in place. This meant the increased use of restrictive methods of supervision and support had not appropriately assessed as in their best interests. This placed people at increased risk of improper or degrading treatment. This organisational culture meant that some people were subject to control or restraint that may not have been proportionate to the risk of harm. The processes and systems therefore failed to protect people from the risk of abuse and improper treatment.

The provider had an electronic system for the recording of incidents and accidents including safeguarding events. The manager also maintained a handwritten safeguarding log for monitoring purposes. The processes in place to record, report and monitor safeguarding incidents across the service were not accurate or effective.

For example, some of the safeguarding incidents reported to CQC were not on the manager’s safeguarding log. The manager’s safeguarding log and the safeguarding incidents recorded on the electronic system also did not match. Some incidents were recorded on the safeguarding log but not recorded on the electronic system and vice versa. It was difficult to get a true picture of safeguarding incidents and whether appropriate action had been taken to prevent harm.

Our observations of care and people’s records showed people did not always experience care that mitigated risks, supported them to move safely between services or to live without restriction

Managers and leaders lacked a clear understanding of how to mitigate some of people risks in the safe delivery of their care. They failed to have sufficient oversight of people’s care and as a result failed to identify that people’s needs were not being met in accordance with their care plan or in a safe way. They were unable to demonstrate that the increased restrictions on people’s liberty were proportionate to the level of risk.

We did not observe any risk taking activity or the support provided. However, records showed that people’s risks were not always effectively managed.

People’s needs and risks were not adequately assessed. Some people had complex needs such as brain injuries, diabetes, and stroke, which were not adequately assessed or care planned. Staff lacked clear guidance on these conditions, the signs and symptoms to spot in the event of ill-health and how to care for them safely.

People’s care plans and risk assessments did not always contain consistent or enough information to guide staff on how to mitigate risks specific to them. For example, one person was at significant risk of urinary tract infections. There was no specific risk management plan in place to advise staff how to support the person to prevent a urinary tract infection.

When a person's needs changed care plans were not always properly updated to ensure staff had correct information on safe care and treatment. For example, one person’s main intake of food and fluid was delivered via a PEG (Percutaneous Endoscopic Gastrostomy). A PEG is a tube that is placed into abdomen, enabling people to receive food, fluids and medicines directly into their stomach, rather than by mouth. This person’s care plan was not properly updated with the latest advice from the dietician. As a result, their care plan contained contradictory and inconsistent advice on the type and amount of food and fluid to be delivered via the PEG.

People’s care was not always provided safely or monitored appropriately to mitigate the risk of harm. For example, one person required a special diet to mitigate the risk of choking. Records showed this person was given food items unsafe for them to eat. Another person living with diabetes, had their blood sugars monitored but records did not show appropriate action was always taken to mitigate the risk of diabetic complications.

Staff did not have sufficient information on people's mental health conditions in order to support their well-being. This increased the risk of people’s distress or behaviours being misunderstood or unrecognised.

People told us the home was clean and well maintained. A relative said, “It is very clean and smells nice. I remember when I first came, I had a good impression of the place”.

People had emergency evacuation plans in place to assist staff and emergency services to evacuate them safely, in the event of an emergency such as a fire.

Staff received training in fire safety, health, safety and welfare. Fire drills were also practiced with staff. It was not clear whether fire drills were practiced with people living in the home.

The manager told us regular health and safety audits took place and provided evidence that fire, gas, electrics and equipment safety complied with health and safety requirements.

The home was clean, well maintained and fit for purpose.

There were systems and processes in place to ensure risks in the environment were identified and addressed to protect people from avoidable harm.

A relative told us, “There are always enough staff, usually I see the same faces but sometimes there are new ones. They are always nice with me”.

One person said, “They could do with some more” but did not offer an explanation as to why.

Most staff members felt there were enough staff on duty to meet people’s needs. Their comments included,

“I think there is always enough staff on duty. If someone calls in sick last minute, there will always be an agency staff member who will come in. If someone can’t come in managers put the shift out to permanent and bank staff first and then go to agency at last resort” and “Yes 100%”.

Staff told us they received training and support to enable them to carry out their role effectively and safely. One staff member said, “We do physical , face to face and online training. First Aid, epilepsy, how to protect yourself, safeguarding training, training to support people who suffer seizures. We always have refresher training, we have an app which we log into and it tells us when our training is due and when we have to complete it by”.

Staff members told us they received regular supervision from their line manager and had an annual appraisal.

During our visit, the number of staff on duty was sufficient to meet people’s needs. Staff attended to people’s needs promptly.

There was no formal dependency tool in place to determine safe staffing levels. The manager told us however there were other checks in place to ensure staffing levels were safe. They said people’s dependency needs, observations, skill mix and feedback from staff and people living in the home were taken into account when staffing levels were determined. The staff rota was reviewed twice a weekly as part of Exemplar’s “Safer staffing reviews”. The regional manager also had oversight of staffing numbers to ensure they were safe.

People raised no concerns about the cleanliness of the environment and told us staff used personal protective equipment (PPE) when providing support.

Staff completed appropriate training in infection prevention and control, food hygiene and were aware of safe hygiene practices. Personal protective equipment (PPE) was available for staff to wear when providing support.

On the day of our visit, the environment well maintained, clean and pleasant. Staff were observed to be bare below elbow in accordance with good hygiene practice.

Regular audits of the home’s environment, equipment and décor were completed to ensure it was clean and well maintained. A monthly audit of infection control and prevention standards was also completed.

There were cleaning schedules in place to identify the areas and items that required daily and weekly cleaning. There were some gaps in these records on review.

There were policies and procedures in place to guide staff in infection prevention and control.

Some people missed doses of their prescribed medicines because there was no stock in the home. This included medicines to prevent seizures, weight loss and to treat pain and constipation. This meant people’s health was placed at risk of harm.

Some people were prescribed medicines to be taken ‘when required’ or with a choice of dose. The protocols to support the safe administration of these medicines were either not personalised or contained conflicting information. Staff had no guidance to follow to help them decide the most appropriate amount of medicine to administer when there was a choice of dose. This placed people at risk of not getting their medicines consistently and at the time they were needed.

Staff told us the service completed audits, however we found they had not identified all the concerns highlighted during this inspection.

Staff told us a medicines policy was in place, but we found staff did not always follow it. For example, staff failed to follow the policy relating to labels on creams which had become damaged. This failure to follow the medicines policy resulted in one person’s creams not being applied for a month.

The process staff followed when administering medicines did not follow best practice or the medicines policy. Medicines could not be signed for at the time of administration because staff administering medicines used a fixed, desk top computer, situated in the nurses’ office to sign for the administration of medicines, rather than a portable laptop that they could take with them on their medicines round.

Nurses signed for creams that they had not applied or witnessed being applied, because creams were applied by care staff. This meant the records relating to their administration were not accurate.

The manufacturers’ directions on when to administer medicines were not always followed which put people at risk of not being given their medicines safely.

Some people needed to be given medicines hidden in food or drinks due to history of them refusing to take the medicines they needed. There was no practical information in place to advise staff which types of drinks people preferred to take their medicines in, to encourage and ensure they were more likely to take their medicines. One person was given all their medicines mixed together in a drink. This was not good practice because if they failed to consume all of their drink, the full dose of medicines would not have been taken. It would also have been impossible to tell how much of each medicine they had taken.

The system in place for managing the treatment of diabetes was not always safe. The shortfalls in the system caused one person on one occasion to experience avoidable low blood sugar levels. Low blood sugar levels (Hypoglycaemia) can cause a range of unpleasant physical symptoms such as dizziness, difficulty thinking, confusion, shaking, fatigue, blurry vision and in some severe cases can cause a loss of consciousness.