Moundsley 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 looked at 7 quality statements under the Safe key question: learning culture, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, infection prevention and control and medicines optimisation. People and their relatives told us they felt safe living at Moundsley House. However, people’s individual risks and environmental risks were not always assessed and mitigated. People told us there were enough staff to care for them and we saw there were sufficient staffing levels on both days of our assessment to meet the needs of the people who used the service.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One person told us, “The manager listens to us. We have lots of meetings, he asks our opinions and keeps us up to date with what is going on and any changes. He has a good team around him. If anything wasn’t right or I was worried I would tell him". Relatives told us communication was good and they were kept informed of their family members wellbeing.

Staff we spoke with understood their responsibilities to record and report accidents and incidents. One staff member told us, “We fill in an accident form which gets saved onto the computer and sent to the manager to look at. We talk about accident, incidents, complaints and any health and safety issues at our meetings”. The registered manager told us they monitored accident and incident forms and referred people to the falls team where necessary but had not routinely completed any analysis to identify patterns and trends. Staff felt their concerns would be listened to by the management team.

We saw from records, and the registered manager confirmed, that accidents and incidents had not been routinely analysed. However, the provider had identified this as an area of improvement and was working with the registered manager to ensure this was consistently completed and actions taken where needed. Meetings were held where staff had the opportunity to raise concerns and share best practice. During our assessment the provider started to take action to address the concerns we found. This demonstrated the providers commitment to learning and improving.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at Moundsley House. One person told us, “They [staff] keep me safe here, the staff here make me feel safe”. Most relatives spoke positively of the staff and the support they provided. One relative said, “I don’t worry about [Person’s name], we know they are safe”.

Staff we spoke with understood how to recognise and report concerns. Training records showed that some staff had received training however, not all staff had completed or undertaken refresher training.

We saw people were not always supported safely which placed them at an increased risk of harm. We have addressed this in the involving people to manage risk section. Staff responded to support people in a timely manner.

The provider had recently introduced a process to review safeguarding data from Moundsley House and other homes within the company to look for trends and patterns. Findings from the review of data was shared with the registered managers as part of a learning process. Mental capacity assessments were completed and Deprivation of Liberty Safeguard (DoLS) applications made. However, we found that some people’s DoLS had expired, this meant some people were being unlawfully deprived of their liberty. Processes were in place to flag when DoLS were due to expire, however, these had not always been acted upon. When we returned for the second day of our assessment the provider confirmed that new applications had been completed and submitted. Care records did not show where others, including family members, had been involved in best interest decisions about people’s care and treatment. When DoLS had been authorised, information was not always relayed into care records. For example, what decisions DoLS had been authorised for and when conditions had been applied, what these were and how they were being met.

Some people told us they were involved in care planning and felt their risks were managed well. One person told us, “They [staff] use a hoist to get me out of bed, I feel safe using that". Another person said, “They involve me in my care, they ask me what I want and don’t ever dictate to me what I have to do”. Where appropriate relatives were also involved, one relative told us, “They [staff] involve me in [Person’s name’s] care, I’m involved in reviews with regards to care and medication”.

Staff we spoke with were aware of people’s associated risks and how these were managed. The registered manager told us that people’s identified risks were talked about at handover. A new handover form had been introduced to record daily discussions. The registered manager acknowledged risk assessments were not in place where they needed to be and actions had been taken to address this shortfall.

Risks were not always managed or mitigated effectively. For example, one person did not have protective bumpers on their bedrails (bumpers are used on bedrails to reduce the risk of entrapment). The provider had not put any interim measures in place to make sure the person was safe in bed whilst they were waiting for a new set of bumpers to be delivered. We saw 2 people being transferred using wheelchairs without the use of footrests, this meant people were at increased risk of injury. We reviewed the care records and found there were no risk assessments in place. Some people were at risk of developing skin damage. Where pressure relieving equipment was in place, we found the settings were incorrect for several people, this increased the risk of skin damage.

People did not always have adequate risk assessments in place. Whilst we found no harm to people, risk assessments were either not in place or did not contain enough information to guide staff on how to provide safe care. For example, some people required bedrails to reduce the risk of them falling out of bed. We looked at 8 peoples records, only 1 person had a risk assessment in place to determine bed rails were safe to use. Records did not always reflect where people had been involved in decisions about risks when they had capacity to do so, or where people lacked capacity that best interest meetings had been held involving relevant people and professionals. We discussed our concerns with the provider and assurances were given risk assessments would be completed or updated. The provider informed us they had ordered bumpers for bedrails and awaiting delivery. We later received written confirmation that bumpers had been put in place following out visit. Risk assessments had been put in place for the 2 people using wheelchairs without footplates and their care plans had been updated. When we returned for the second day of our assessment mattress settings had been adjusted to the correct setting.

People told us they felt the environment was safe. One person told us, “If I ring my buzzer they [staff] come. I don’t ever have to wait long for someone to come to help me”. Another person told us, “They [staff] make sure I’ve got my frame to help me walk safely. I feel safe here”.

The registered manager told us they completed daily walk arounds where they would identify any concerns. Staff told us weekly fire tests were carried out and they attended regular fire drills. Staff we spoke with were confident of the actions they were required to take the event of the fire alarm activating. Records showed regular tests and drills were carried out.

The environment was not always safe. We found 3 windows had not been fitted with window restrictors, 2 of which on the first floor. Cleaning products were not always safely locked away, which meant people could access cleaning products which could cause them harm. Other items which may cause harm, for example, razors and medicinal creams were not securely locked away . The lock to the kitchen door was broken giving people access to high-risk area where harm could be caused, for example boiling water and hot surfaces. We discussed our findings with the provider who gave us assurances they would address the concerns. When we returned for the second day of our assessment the provider had started to take action to address the concerns. The 3 windows had been fitted with restrictors and checks carried out on all other windows, new cleaners’ trolleys with lockable units had been ordered and discussions held with staff regarding safe storage of chemicals.

Provider oversight to ensure the environment was safe for people to live in was not always effective. Daily walk arounds and quarterly environment audits were carried out by the registered manager. Findings were added to the maintenance log and discussed at daily meetings. However, where concerns had been identified, measures had not been put in place to mitigate risks whilst waiting for remedial action to be taken. For example, the provider had identified the lock to the kitchen door was broken and had ordered a replacement. No interim measures had been put in place to ensure people did not come to any harm. Following our assessment the provider confirmed in writing that the kitchen door had been secured whilst waiting for delivery and fitting of the new door. Processes to check if window restrictors were in place and were in good working order were not effective and had not identified some windows did not have restrictors fitted. The provider gave us assurances this would be addressed, when we returned for the second day of our visit, window restrictors had been fitted. Equipment was regularly serviced, and records kept. People had personal evacuation plans (PEEPs) in place and were reviewed and up to date.

People and their relatives gave mostly positive feedback. One person told us. “The staff are all really nice and polite, they would do anything for you”. A relative said, “Staff are always friendly, There’s always a lot of staff around, there’s more than enough of them”. However, one relative told us, “The agency staff of a weekend have no compassion and don’t understand [Person’s name] needs.

Staff we spoke with told us there were enough staff to meet people’s needs. New staff were provided with an induction period which included training and shadowing with permanent staff. One staff member told us, “We do a lot of teamwork, we are here to give a quality of care the residents deserve and need and we respect their wishes”. We gave feedback to the provider regarding the concerns raised regarding weekends and agency staff. The provider told us there would be a weekend rota for on site management cover commencing 20 June 2024 covering all 3 of the providers care homes. Following our assessment the registered manager informed us they had addressed the concerns with the agency who provided the temporary staff.

We observed staffing levels during our visit, call bells were responded to in a reasonable time. Some people called for staff when they required support, most of the time staff responded in a timely manner. Other staff provided support at mealtimes to ensure people who required assistance were not waiting a long time. We observed family members were also involved in supporting their loved ones at mealtimes. We saw the activity team providing people in the communal areas with plenty of stimulating activity including keep fit, games and music.

Staff were recruited safely, and appropriate checks were carried out as required. However, we noted on 3 staff files we checked there was no account recorded for gaps in employment history. We discussed this with the provider, when we returned on the second day of our assessment the provider assured us this information had been discussed but had not transferred onto the staff files and gave assurances this information would be included in the future. All other checks including those on agency staff were satisfactory. The provider was not using a dependency tool to assess the staffing levels required but were looking at implementing this. Staff completed a range of training courses which provided them with the range of skills and knowledge required to meet people's care needs

Relatives we spoke with were positive about the cleanliness at Moundsley House. One relative told us, “Every time I come it’s clean and tidy. [Relatives name] is always clean and looked after”. Another relative said, “ The cleaners are always here wiping the chairs and the floors. It’s always very clean”.

The head of operations told us an infection prevention and control (IPC) lead was in the process of completing training to become the IPC champion. Most staff had completed or were in the process of completing IPC training.

We found the service to be clean and tidy and free from odours. We did however find hand sanitiser units were empty, the registered manager confirmed that individual hand sanitisers had been issued to staff. However, no provisions had been made for visitors. Some foot operated bins were broken, and some were soiled. On the second day of our assessment, we found that most sanitiser units had been filled and bins had been deep cleaned. The provider told us they had ordered new bins to replace the broken ones. Oral care was not always provided to people, we found some people did not have a toothbrush or toothpaste or their toothbrush was dry and hard. Care records were not always clear if oral care had been provided or declined.

The provider had a policy in place for IPC and was in the process of reviewing and updating this. Audits were carried out every 3 months and the findings added to an action plan monitored by the provider. We reviewed the most recent audit and saw where shortfalls had been identified, actions taken to address these had been recorded.

People were happy with how their medicines were managed. One person told us, “They explain to me what my tablets are for. I get them every day”.

The provider told us they had systems in place to audit medicines, including daily checks, monthly audits, and external audits from a pharmacy. Staff told us they had received training in the administration of medicines and their competencies regularly assessed.

Regular audits of medication were carried out. Where actions were identified, these were acted upon and a record made of the actions taken. Some people required their medication to be given covertly. Records were in place to show that people’s capacity had been assessed and best interest decisions made involving family, GP, and a pharmacist. People who had been prescribed 'as required' medicines had guidance in place to show staff how and when this should be administered. Whilst we found no concerns regarding the management and administration of oral medicines, we identified that medicinal creams were not stored safely, some were not labelled or where labels were present these were not always clear. The opening dates of creams was not always recorded, this increased the risk of medicinal creams being ineffective due to being out of date.