Crossways Nursing Home

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

Incidents and accidents were reported; however, documentation to show how lessons learned were shared with staff was not always in place. Some incident forms contained contradictory information, contained minimal information and some key information was not recorded. Potential risks to people’s health and welfare had been assessed and reviewed regularly. Some information in care plans was not always consistent and some areas of detailed guidance was not always included in people’s care and support plans. The environment was visibly clean but not always well maintained. There was a maintenance plan in place, but this lacked clarity regarding what actions had been completed and who was responsible. Some shortfalls were identified regarding the recruitment process for some new members of staff because employment histories were not always fully complete. Shortfalls were identified in the management of medicines; these included poor record keeping and topical creams and lotions not always having their opened date recorded. The medicine audit had not identified the shortfalls highlighted during our assessment.

There were enough staff to meet the needs of people and staff knew how to support people safely, as individuals. Staff followed safeguarding processes. Processes were in place to manage safeguarding concerns. People told us they felt well supported by staff.

This service scored 72 (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 their relatives told us they felt supported by the staff team and felt safe. Staff provided support in a safe and calm way. Staff followed safety guidelines as required.

Staff were encouraged to report incidents. Staff told us, “I would check how serious the [incident] was and inform the GP. I would complete an accident/incident report, inform the relatives, document any changes and continue to observe the resident for 72 hours” and, “I will press the emergency buzzer. I won’t move [people] until the nurse has seen them. We need to check that their legs and hands are okay and that they’re safe to move. If we’re told they are okay, then we will either hoist them or support them to stand.”

Staff told us they were informed when incidents and accidents occurred. Comments included, “The management will call a meeting” and, “Our manager and nurse will inform us if something has happened, and someone went to hospital. They will tell us if anything has changed because of the incident and keep staff updated.”

Incidents and accidents were reported. Staff documented any injuries sustained on body maps. However, monthly accident report audits contained minimal information, and the full name of the person involved was sometimes not recorded on the incident forms we looked at. In the monthly audit report for June 2024, there was no information documented to evidence who the report referred to. Some forms contained contradictory information; for example, one incident report investigation form stated the incident was “not witnessed” however the accompanying monthly incident report audit stated the incident “was witnessed”.

Incidents were investigated. When necessary care plans were updated to reflect any change in guidance for staff. However, there was no evidence of lessons learned being shared with the team. The registered manager said they did this by speaking at team meetings, but minutes of meetings we looked at did not provide information of what was shared with staff. After the assessment the registered manager told us they had reviewed the format and minutes of staff meetings.

People and their relatives said the service supported them to attend external appointments, such as hospital appointments.

Staff told us they worked well with health and social care professionals and had developed good working relationships. Staff told us they supported people to attend hospital appointments if needed.

We sought feedback from health professionals who work with the service. No concerns were raised about this quality statement. One health professional said, “[Staff] are good at contacting me with any concerns and clearly know their residents well.”

There were clear processes in place to ensure people’s current information was safely shared with health and social care professionals.

A member of staff from the GP team visited weekly. Records showed people were reviewed by health professionals such as community mental health teams and other professionals when required. For example, records showed people were reviewed by a speech and language therapist (SALT) if swallowing concerns were noted by staff. The service used a nationally recognised tool to assess and respond when people’s condition deteriorated. This is a key element of patient safety and improving patient outcomes.

People told us they felt safe. Comments included, “Yes, I do feel safe here” and, “Yes, I do feel safe. The carers are mostly helpful.” People’s relatives told us they felt confident their family member was safe. Comments included, “[Name] is absolutely100% safe. There has always been enough staff, and the staff are responsive, professional and efficient” and “Is [name] safe? An unreserved yes.”

Staff had been trained and understood their responsibilities to keep people safe from avoidable harm and abuse. One staff member said, “It’s about whether our residents are being abused. If we see abuse, then we need to inform authorities. Firstly, I would inform my manager and operations manager.”

We observed staff interacting with people in a safe way.

There was a safeguarding and whistleblowing policy that gave staff clear guidance to follow in the event they needed to refer any concerns to the local authority. Referrals had been made to the local safeguarding team appropriately

The manager kept a log of deprivation of liberty safeguard applications and authorisations, although this wasn’t regularly reviewed. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with DoLS. This meant people’s rights were fully respected.

Some people told us they felt staff avoided risks rather than managing them. One person said, “Generally I am happy, but I do get cross occasionally. They [staff] sometimes insist you do something in case you fall.” People’s relatives raised no concerns about risk management. One person’s relative said, “[Name] can be violent and aggressive, but staff recognise when it is better to stop and go away before trying again.” Another person’s relative said, “[Name] is safe, very much so, and much safer than when they were living at home. At home they had lots of falls.”

Staff understood the risks associated with choking and skin damage. Staff told us they knew who was most at risk and knew what to do if someone choked for example. Staff knew how often people required support to change position and how to do this safely.

One staff member said, “It’s quite safe here. If a resident wants to walk around, then they can go out in the large garden as well, but at the moment it’s too cold, so they walk around the home. Some of the resident’s upstairs can walk. We don’t allow them to walk down the stairs on their own though.”

We observed people sitting in the communal lounge on both days of our assessment. Staff were stood in the doorway of the lounge observing people, and if people wanted to move around, staff walked with them. The service used an electronic care planning and documentation system. A nurse showed us how the system alerted them if people’s fluid intake was low for example. This meant there was continuous monitoring by nurses on duty.

Potential risks to people’s health and welfare had been assessed and risk assessments had been reviewed regularly. However, there was not always detailed guidance about how to support people when they were distressed and displaying physical or verbal aggression, and information about any known triggers was not documented. The information contained in some care plans was not consistent, such as how often people needed support to change position. There was no choking risk assessment in place for one person despite this being documented in the person’s care plan as a known risk. There was no diabetes plan in place for another person. Some people were at risk of isolation, but care plan the guidance did not reflect their specific needs and give specific guidance for staff to reduce the risk of becoming isolated. People had been assessed for the risk of skin damage, but care plans were not always clear about how often people needed staff support to change their position. We discussed this with the deputy manager during the assessment and they said they would update the care plans accordingly. After the assessment, they confirmed told us they had updated care plans based on our feedback. The service had only recently changed from paper to electronic records. Paper records we saw did contain all information, but at the time of the assessment this had not been transferred into the electronic records. However, staff were working from the newer electronic records.

Pressure relieving equipment we looked at was set correctly.

Some people had been assessed as being at risk of malnutrition. Plans included information for staff such as food preferences, frequency of monitoring people’s weight and any specialist advice that had been sought. When people were having their food and fluid intake monitored, records showed people were provided with enough to eat and drink.

Bruises and skin tears were reported.

People did not raise any concerns about the environment. One person’s relative said, “All my friends who come here say how tatty everything is and that the home needs an upgrade.”

The registered manager showed us the maintenance plan for the service dated January to December 2024. They told us, “Most of the furniture does need changing; we are in the process of doing that.” Other staff we spoke with felt the environment was safe. Staff told us they had all the equipment they needed to carry out their roles and that it all worked well.

The environment was visibly clean but not always well maintained. Some of the paint work we saw needed refreshing. Some furniture items were worn. There were flies in one person’s bedroom which staff were aware of, but no action had been taken. The provider purchased a fly screen on day two of the assessment after we raised our concerns. The sluice room was not always kept locked and was dimly lit, and there was an unidentified fluid in a bottle beside the sink. The building was old and there was limited storage space available. An unlocked garden shed, accessible to people, was being used to store items such as personal protective equipment (PPE), incontinence pads, non-confidential paperwork and pots of paint and was cluttered. We also observed boxes of PPE stored in one person’s bedroom. After the assessment the registered manager told us these items were in the person’s bedroom for a short period of time before being distributed around the home.

There was a large garden and patio area to the rear of the building. We were told people regularly used this during the warmer weather.

The service had been reviewed in July 2024 by the fire safety officer who was satisfied with the service’s fire safety, although suggested that further improvements could be made. The registered manager showed us areas that had been improved, and we saw some things had yet to be actioned, but there was no action plan in place for this. For example, one bedroom door did not close properly.

The environment was tired and in need of refurbishment. Feedback we saw from people’s relatives showed comments had been made, such as, “Building and décor needs a facelift", "Cleaning paintwork and minor maintenance needs to be done a bit more often." Although there was a maintenance plan in place, the plan covered a 12-month period. It was not clear when issues had been identified and the column to show when actions had been completed did not always refer to the originally identified issue. We discussed this with the management team after the assessment and they said they would review this.

We reviewed records of checks carried out to ensure the premises were safe. This included gas, electrical and fire safety checks. Personal evacuation plans were in place. We saw these had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency.

None of the people or relatives we spoke with raised any concerns about staffing levels. People told us if they needed to call for staff, they could, although some people said response times varied. Comments included, “I have a call bell in my room. I don’t use it very much at all. At night, I would shout; there is always someone downstairs at night” and “If you ever need anything at all there are enough people to look after and help you.” One person said, “I do use [the call bell] sometimes and [staff] do respond. Overall, the response times are adequate, but the time of response does tend to vary. The trouble is there is not always such a rapid response to the situation as you would like.”

Staff raised no concerns about staffing levels. Staff comments included, “I think we have enough staff because we only have 13 people living here” and, “Yes, we have enough staff. It’s a small nursing home. If we have a full house, then we would have more staff than that.”

Call bells were answered in a timely manner. The service audited call bell response times, to help ensure that appropriate numbers of staff were in place. Nurses had the skills to meet people’s physical and mental health needs, including medicines management. We observed staff spent a lot of time in the lounge with people, but did not engage people in meaningful conversation and for periods did not sit with people but stood as if they were monitoring them. We observed staff put the TV on but not ask people what they would prefer to watch. We saw that people were not rushed, and staff supported them at their own pace. At lunchtime staff supporting people with their meal, spent their time solely with the person, and people and staff appeared relaxed.

The registered manager showed us the dependency tool the service used to calculate staffing levels.

There was a process in place for staff to receive regular supervision, however, record keeping in relation to supervision sessions was not detailed. New staff employed by the service had not always been recruited safely. All background checks, including the right to work and reference checks, had been completed.

People using the service, and their relatives did not share any concerns about this quality statement.

Staff had been trained in infection prevention and control. Staff knew when and why they needed to wear personal protective equipment (PPE). One staff member said, “The most important part [of infection control] is the hand washing. Before going to do anything, you have to wash your hands first. After helping 1resident, before going to the next one you have to wash your hands.”

We observed staff wearing aprons when supporting people with meals. We saw stocks of PPE around the building for staff to use.

Measures were in place to prevent and control infection. Staff had been trained in infection prevention and control and knew when and how to apply personal protective equipment (PPE) and when and how to safely discard it after use. Housekeeping staff were on duty 5 days a week. There was enough PPE available for staff to use. Regular infection prevention control audits had been carried out. These included audits of the environment, equipment and staff handwashing.

People using the service did not raise any concerns about this quality statement. People’s relatives said, “The meds are all under control now.” Another person’s relatives stressed how knowledgeable [deputy manager] was in relation to medicines.

Staff who administered medicines had received up to date medicine training and had their competency checked.

Systems were in operation to order, store, administer, record and dispose of medicines. Not all systems were effective. Stock balance checks of controlled medicines had not identified an incorrect stock balance recording despite twice daily checks. This was addressed by the deputy manager during the assessment. The temperature of storage areas including medicine fridges was monitored; however, staff had not monitored minimum and maximum temperatures of the fridge. Staff had made handwritten changes to some of the medicine administration instructions but had not signed or had the amendments checked and countersigned by another staff member to ensure accuracy. When people were prescribed additional medicines on an as required basis (PRN) for agitation or distress, protocols did not contain sufficient guidance for staff on steps to take before resorting to the use of medicines. Topical creams and lotions had not been dated when opened to help staff know when they had expired, and we saw bottles of creams and lotions in communal bathrooms instead of being stored safely in people’s bedrooms. Regular medicine audits were carried out, however there was no action plan to rectify shortfalls and none of the issues we observed had been identified during audits. We discussed this with the management team after the assessment. They told us PRN protocols had been reviewed.

Medicine administration records were all signed to indicate people had received their medicines as prescribed.