Morton Close

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

Safe - This means we looked for evidence that people were protected from abuse and avoidable harm. We rated the service Requires Improvement. Risks to people’s health, safety and well-being were not always robustly assessed and systems to learn lessons when things went wrong were not managed consistently. Staff had training in safeguarding, but we found some shortfalls in management reporting. Medicines were not always managed safely but the provider responded promptly and made improvements. Safe recruitment processes were in place and there were enough trained and competent staff to support people. The environment was safe and well-maintained.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives did not provide specific feedback about how the provider learned lessons. 1 person told us they had moved rooms due to the risks relating the stairs.

Staff understood how and when to complete an incident record and told us they were updated when events occurred. The manager told us they had improved how they reviewed safety events in order to learn lessons. They had also attended external falls analysis training which supported them in analysing events when people were experiencing falls.

Improvements were required to the provider’s systems to investigate and evidence learning to continually embed good practice. For example, accidents and incidents were recorded but there was not always evidence to show action had been taken to mitigate the risk of events recurring. People's care plans and risk assessments were not routinely updated after events. The provider had a complaints log but not all concerns were recorded, which meant there was not a full overview of potential themes and trends. This meant opportunities to learn lessons were not always taken. When we visited in July 2024, we found some improvements had been made to how complaints, accidents and incidents were recorded and reviewed. However, we continued to identify areas where learning had not been taken. For example, when we visited in April 2024, we highlighted safety concerns about a person accessing the stairs, but robust action had not been taken to ensure the risks were fully assessed for other people living at the home.

People and relatives told us there were good systems in place to promote continuity of care. They told us they felt supported when they moved into the home and received good information and a safe transition. We asked people about their experience moving into the home. One person said, “It was good. They were expecting me, everything I needed was in my room ready for me. They [the staff] let me settle in and then showed me round again. No complaints at all.” People and relatives told us links with health professionals were good.

The manager confirmed they had made changes and took ownership when new people were admitted to the home. They told us they worked closely with people, relatives and other professionals to ensure safe pathways and transitions were in place.

Overall feedback showed there had been improvements at the home and the manager was liaising with stakeholders. It was reported continued improvement was required in relation to note taking. One health care professional reported whilst the manager responded to advice this was not always safely reflected in people's care, but professional advice was sought. They said, "They are improving but still need support in certain areas and a lot of education and training. [Name of manager] does seem to take on advice but the struggle is getting the carers to take this on board."

When we visited in April 2024, we found the provider did not have safe transition pathways, particularly when people were moving into the home. People were assessed before they moved in, but information was not transferred into accessible care plans to enable staff to provide safe care and support. For example, 1 person had been assessed to need regular repositioning due to their skin integrity, but this had not been communicated to staff and there was no evidence repositioning plans were in place. This meant the person was at risk of harm and poor care. The provider responded promptly to our findings and told us they would suspend new admissions until robust processes were in place. When we returned in July 2024, we found the manager had made improvements to the admissions process but further improvements were required to ensure detailed information was gathered. People were supported to have access to health and social care professionals when required.

People told us they felt safe and knew who to speak with if they had any concerns. Comments included, "It is so much better than being on my own at home. I felt very lonely and a bit at risk in my own home, but I don’t here" and "My [family member] has been here for 2 years and the family do not have any concerns over how safe [family member] is here."

Staff received training in safeguarding. They understood how to recognise abuse and poor care and report this to their manager and other relevant professionals.

We observed kind and respectful and interactions between staff and people. We did not observe any safeguarding concerns in relation to staff’ approach to the safe delivery of care.

Safeguarding logs were in place but we found examples where safeguarding events had not been reported appropriately by the manager. For example, in April 2024, we found 1 person had sustained unexplained injuries, and this had not been robustly investigated or reported to the relevant safeguarding authorities. In July 2024 we found improvements had been made to safeguarding processes. We saw evidence the manager had worked closely with the local authority safeguarding team to investigate and address safeguarding events.

People told us they felt safe and secure. People were supported safely with moving and handling. A relative told us, "The staff need to use a hoist for [name of family member]. There are always 2 staff and they are gentle with her."

Staff understood the risks people were exposed to and told us they were kept up to date with changes in people’s needs. One staff member told us, “We find out if people’s needs have changed in their care plans and in handover.” However, we found not all care plans contained up to date detailed information.

Our observations showed staff were mainly attentive and responsive to people's needs. Risks to people's care were generally well managed and staff followed safe practices.

However, we also observed times when risks were not managed in accordance with people's risk assessments and care plans. For example, we observed 1 person whose risk assessment stated they should be supported by staff when accessing the patio area being left without support. In July 2024 we observed 1 person who was assessed to be at risk of falls accessing the staircase unwitnessed by staff, which meant they were at risk of potential harm. We discussed this with manager, and they took prompt steps to address this.

Risks to people’s health, safety and welfare were not always managed safely which meant people were exposed to the risk of harm and poor care. Some risk assessments were in place but they were not always accurate or up to date. For example, in April 2024 one person’s care records contained contradictory information about their mobility needs. One part indicated they walked independently, another part stated they required the use of walking stick and a zimmer frame. Where people experienced periods of distress and anxiety, robust risk assessments were not in place to advise staff how to support people safely and consistently. In July 2024 we found processes had improved but we continued to find multiple examples where risk assessments were not updated following significant events, such as falls and inconsistencies in people’s care plans which meant staff did not have clear guidance on how to support people safely and consistently.

People and relatives expressed their satisfaction with the environment, including the outdoor space, communal areas and their bedrooms.

We saw there had been environmental improvements to the home. People were provided with a safe and homely living space. Where equipment was required, this was in place and well maintained. Dementia friendly signage and symbols were in place to support people to orientate around the home.

The provider had safe systems in place to ensure the building was maintained safely, including regular checks and audits. The home employed a maintenance worker which meant any issues were dealt with promptly. During the assessment we highlighted risks relating to access to the stairs. The provider took prompt action to address this. There was an ongoing programme of refurbishment and people were involved in this development. For example, an outdoor covered space had been recently created, as a result of a request from people.

People and relatives told us there were enough skilled staff on duty to support them safely. Some people said they sometimes had to wait for support, but they did not raise any concerns about this.

Most staff said there were enough staff on duty to provide safe care and support. They described good teamwork and communication. However, some staff said they did not always think the provider responded promptly to increase staffing levels where the numbers and needs of people changed. We fed this back to the provider during the assessment.

We observed there were enough staff to support people. People who preferred to stay in their rooms had access to call bells.

The provider followed robust staffing processes to ensure staff were recruited, inducted and trained in their role safely. The provider used a recognised dependency tool to assess how many staff were required to support people safely. This was reviewed regularly if new people moved into the home or people’s needs changed. However, the tool did not clearly show how the breakdown of staff was calculated between day and night shifts. When we returned in July 2024 the provider had addressed this.

People and relatives did not raise any concerns about how infection, prevention and control was managed within the home. One person said, “Everywhere is nice and clean, especially the toilets and bathrooms.”

Staff confirmed they had received training in infection, prevention and control. Personal protective equipment (PPE) was available in strategic locations around the home.

We observed staff were not adhering to the provider’s infection prevention and control policy when we visited in July 2024.We observed 4 out of 5 staff were wearing jewellery, including stoned rings and bracelets. Overall, the home was clean, and staff wore the recommended PPE where required.

Staff had received up to date training in infection, prevention and control practises. The provider had an up-to-date policy in place. However, when we visited in July 2024 staff were not fully adhering to the policy. The provider’s audits also indicated non-compliance had been identified previously but robust action had not been taken.

People and relatives did not raise any concerns about how their medication was managed. One person said, “Yes I get my tablets when I should do.” We saw examples of people’s preferences being considered when administering their medicines, including pain relief. Staff administered medicines in a kind and unobtrusive manner.

Staff told us about the improvements they had made to the storage of medicines and medicines waste. In April 2024 the manager told us they did not have training in medicines, but this had been addressed in July 2024 and the manager had undertaken training and had increased oversight of medicines processes.

Since the last assessment the provider had made some improvements to how medicines were managed but in April 2024, we were not assured they were always managed safely. Stock of medicines were not managed efficiently and systems for ordering medicines were not effective. There was evidence of 1 medicine out of stock for 7 days, inaccurate stock counts and medicines being unnecessarily destroyed when still in use. Prescribed medicines for anxiety were administered to people with no clear record of reason, outcome or monitoring post administration. There was no clear guidance for staff to manage people with diabetes. In July 2024 we found the provider had responded to our findings. The medicines policy had been updated by the provider and improvements had been made, however some aspects of medicines management needed clarification for staff to be able to follow properly. Staff completed regular audit checks to make sure medicines were managed safely. We checked records and stocks and found they were correct. There were no gaps in administration records which meant people received their medicines as prescribed.