Moors Park House

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

We identified three breaches of regulation. Staff did not consistently protect people from abuse and improper treatment and did not always identify allegations of abuse or make referrals in line with the services’ policy. Staff did not always monitor people’s health conditions or care provided to ensure it was in line with people’s identified needs. Medicines were not always well managed. Risks relating to the environment were not always monitored or well managed. There were not always enough staff to meet people’s needs, and people’s needs were not always fully assessed before they were admitted to the service. The processes and systems in place to manage potential risk of harm to people were not always effective. Improvements had been made to recruitment processes and staff training. People and their families told us they felt risks were well managed, and people were safe. Community health professionals told us they worked well with staff at Moors Park House and felt confident they supported people to access healthcare professionals. Improvements had been made to medicines records. Important information about people was now held within the medicines administration records (MAR). This included confirmation of identification and any allergies people may have.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst people and their families told us they felt safety was a priority for the service, we found people had experienced repeated incidents of a similar nature. This was because risks weren’t always identified or managed, so people did not benefit from a culture that pro-actively managed risk, which put them at risk of harm.

Staff told us they felt confident raising concerns, however, they were not confident they were always acted on. Some staff told us they raised repeated concerns of a similar nature, but “nothing changed”. Managers told us they were keen to learn from incidents but did not demonstrate they had effectively reviewed or investigated them.

Processes in place did not support a learning culture. Incidents were not investigated thoroughly and there was little learning demonstrated where things had gone wrong. Management of safety incidents was largely re-active, and processes did not support staff to learn lessons or embed good practice. A service improvement plan had been completed by the local authority quality assurance team, but was not kept up to date or fully implemented by managers.

Because people’s needs were not always fully assessed prior to admission, some people’s transitions between services did not go well. In some cases, this meant their placement at Moors Park House ended. Some people had more positive experiences, and were supported for short periods of time at Moors Park House, before returning home. People were supported to access healthcare when required.

Staff told us they did not always have accurate information made available to them prior to a person being admitted to the service. In one case this led to a medication error. Staff had raised these concerns appropriately. Staff were confident they knew people well and sought healthcare advice where appropriate.

Community health professionals told us they worked well with staff at Moors Park House and felt confident they contacted them for support with healthcare management at the appropriate time. Health professionals supporting people’s discharge from hospital felt staff did not always fully utilise the support available to them, when considering the suitability of a new placement.

There were processes to support people and their families to have access to healthcare professionals where required. Whilst admission processes were not always robust, there were processes in place that ensured where people were taken or admitted to hospital, key information would be sent with them.

People experienced harm because they were not protected from abuse. Some people experienced physical and sexual assault and there were a significant number of incidents where people were in conflict with each other. On more than one occasion these incidents were significant enough for the persons placement to be ended. There were also 9 incidents where people left the building unaccompanied, where they had been assessed as unsafe to do so. This put people at significant risk of harm.

Staff told us they felt confident in reporting safeguarding concerns, however, they were not always acted upon by management. Staff told us that risks were not always communicated well, and they were not always told where there had been incidents that affected people’s safety. Managers did not always recognise when incidents constituted a safeguarding concern.

We observed staff were respectful towards people. Our observations were positive, and people looked at ease with staff. We found no evidence of unnecessary restrictions on people.

Managers did not always review, analyse or report safeguarding incidents. They did not follow their own internal policies and failed to report a significant number of incidents to the local authority. Known safeguarding risks were not mitigated effectively. Risks assessments were not always completed to ensure staff with a criminal conviction were suitable to work at the service.

People’s risks were not consistently well managed. For example, where people expressed emotions or distress, staff didn’t always have the skills to manage it in a positive way which minimised distress or conflict. Risk assessments were in place to ensure any restrictive practices were fully assessed and in the persons’ best interest. People’s relatives told us they felt confident their relative was safe at Moors Park House. One relative said, “Overall I have been very pleased with the staff and the running of Moors Park House. I feel my Dad is safe and well looked after”.

Staff were aware of risks posed to people. They had access to care plans and risk assessments.

We saw people being supported to manage risk. For example, staff used safe moving and handling techniques to assist people and took their time to help people mobilise safely.

The processes and systems in place to manage potential risk of harm to people were not always effective. Records did not demonstrate people’s risks were always managed in line with their care plan. For example, one person needed repositioning every 2 hours, however their care records showed gaps of up to 12 hours. There were no systems in place to monitor how much people drank, or to identify when people might be at risk of constipation. Whilst we did not identify significant impact to people, this placed them at risk of harm. There was no effective process in place to monitor if these records had been completed.

People were cared for in an environment which was generally suitable to their needs. Work had recently been completed in an outside courtyard, which provided a pleasant space for people to use. There was a programme in place to ensure upkeep of the premises. For example, the dining room floor, which the provider had identified as an infection control risk and trip hazard, was due to be replaced at the time of this assessment.

Staff told us they had received training on the use of the equipment within the service and felt competent using it. The provider told us contracts were in place to ensure equipment was regularly serviced and maintained.

During our assessment we observed the environment to be clean, tidy and well maintained. Equipment in the service used to support people was observed being used correctly by staff.

We reviewed the systems and processes in place relating to the management and oversight of environmental risk and safety. Whilst some processes were effective the absence of others exposed people to risk of harm. There were no checks being carried out to ensure water was delivered at a safe temperature. We found several taps running at temperatures which could cause scald injuries. No fire drills were taking place and other routine maintenance tasks to ensure the risk of fire was well managed had not been completed.

People told us they sometimes waited a long time for staff to assist them. One relative said, “Dad sometimes says there’s not enough staff, he tells us there’s a lot of agency staff, who don’t always know what they’re doing”.

Staff told us there were not always enough staff to meet people’s needs, and a high reliance on agency staff impacted people, particularly where agency staff hadn’t worked at the service before. Staff had raised concerns about this with managers. Staff told us the staffing levels sometimes meant people did not get out of bed or have a bath or shower. They told us they didn’t have enough time to spend quality time with people. One staff member said, “People do have to wait (for assistance) on a daily basis because of our current staffing numbers”. Another staff member told us, “We really could do with more staff, we pull together but it’s not good sometimes and we can feel rushed”.

The service was busy and we observed people waiting for staff to assist them. We heard call bells ringing and tripping to emergency bells when they weren’t answered. We saw people looking for staff and becoming frustrated because they wanted a drink or some reassurance but, could not find a staff member to help them.

A dependency tool was in place, however, it was not clear that this fully reflected people’s care needs, and the manager told us they did not have confidence in the tool being accurate. The local authority raised concerns about staffing levels in relation to the contracted number of care hours. There were no systems in place to monitor call bells or staff response time. Whilst there was an electric call bell system in place, managers told us it was not possible to analyse the data. There had been improvements in the completion of staff training since our last inspection, and a training matrix was now in place, however, not all staff had yet completed the required training. Although some staff told us they had had supervision session with the manager, these had not been regular or consistently completed for all staff.

People and relatives we spoke with were positive about the cleanliness and appearance of the service.

Staff told us there were dedicated cleaning staff and systems in place to ensure people’s bedrooms and communal areas were regularly cleaned.

We saw staff using personal protective equipment appropriately. The premises was clean, however, some carpets held a stale odour and some surfaces, such as window frames and sills, were difficult to keep clean due to their poor repair.

Whilst we observed the service was generally clean, tidy and free of odour, there were insufficient systems and processes in place to ensure people, visitors and those employed within the service were fully protected against infection control risks. There was no infection control audits completed that would identify any areas of risk or staff practice that could be improved to mitigate potential risk.

People did not always receive their medicines safely. There was a high number of medicines errors, and staff could not always be sure if people had received their medicines correctly or not. People’s medicines were seen to be given in a safe and caring way. Staff took time with people to support them to take their medicines.

Staff who administered medicines told us they had received training and felt competent to do so, however, one staff member raised concerns about the number of medicines errors and medicines not being signed for. They told us this had been raised in staff meetings, but not resolved.

Improvements had been made to medicines records. Important information about people was now held within the medicines administration records (MAR). This included confirmation of identification and any allergies people may have. Medicines were stored securely, including medicines that required additional security. However, the maximum and minimum temperature range in the medicine fridge was not recorded consistently, in line with best practice. Topical cream administration records did not assure that prescribed creams were used as directed. Some people's topical cream records contained directions for staff to follow, while others did not. Where people were prescribed variable dose medicines, staff generally recorded how many tablets had been administered. This helped to ensure people received a safe dose of their prescribed medicines. However, the outcome record to evaluate the effectiveness of this prescribed medicine was not always completed. Audit systems were in place, and we could see some errors, such as missing signatures, had been identified. However, the provider did not always act on the shortfalls effectively or in a timely way to prevent recurrence.