St Cyril's Neurological Care and Rehabilitation Service

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

People’s needs, risks and care were not always assessed, managed or delivered safely to mitigate the risk of avoidable harm. The management and administration of medicines was unsafe which increased the risk of medicine related harm. Learning from accidents and incidents was not actively shared and promoted to prevent a similar event occurring again. Safeguarding procedures were in place and staff were trained and knew how to recognise and respond to potential abuse. People told us they felt safe and able to raise any concerns they had about their care with the staff team. Staff were recruited safely and the number of staff on duty to meet people’s needs was sufficient. People told us staff came quickly when they needed help. Records confirmed staff received mandatory training in appropriate topics relevant to their job role. However, induction, supervision and appraisal systems were not effectively implemented to ensure good staff practice and support. The home was clean and well maintained, however environmental risks were not always recognised and managed safely to prevent harm. Daily checks of potential risks in the environment were not undertaken. Overall, infection control was managed safely, however we observed a small minority of staff who were not bare below elbow. This is important to minimise the spread of infection.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they would feel comfortable raising any concerns they had with the staff team. Most people felt listened to. Their feedback included, “ I could talk to anyone” and “I could tell any one of the staff”.

Staff told us they felt listened to and could raise any concerns they had with the management team. They told us that they were asked for their suggestions and were given feedback on the service at staff meetings. Staff were encouraged to play an active part in any service improvements.

Staff meeting minutes showed that staff were encouraged to discuss any concerns and share any feedback they had on the service, the current ways of working and any improvements they think could be made. There were however no other mechanisms for staff feedback such as surveys or up to date supervision meetings. Accident and incident records were maintained with actions taken following the accident and incident recorded. There was no evidence however that any learning from accidents and incidents was shared with the staff team to promote continuous improvement.

People and their relatives told us their needs and risks were assessed prior to admission to ensure the service could safely meet their needs. Everyone told us staff were kind and welcoming when they first arrived. One person told us, “They have made me feel safe and welcome and comfortable in bed. They knew I was worried on my first night here and they promised to check on me every 30 minutes and they did”. We found however that although people’s needs were assessed prior to admission, ongoing care planning and risk management was chaotic and disorganised. It was impossible to tell from people’s care files what their current care and treatment needs were, and difficult to understand what care and treatment they needed to ensure the support they received was effective. Accurate, contemporaneous records had not been maintained.

The management team advised referrals were received and accepted from hospitals across the North West. Referrals were based on a person’s neurological presentation after an acquired brain injury. An assessment of the person's needs was completed prior to and on admission to the service, after which care and risk management plans were developed.

Partner feedback about the assessment process was positive.

The processes in place to ensure safe systems of care were not safe or effective. People's risks were not always clearly identified and risk management plans were not always appropriately updated throughout a person's treatment journey. This meant risk management information was sometimes unclear and not an accurate description of a person's current level of risk. This meant that staff lacked important guidance on how to keep people safe. It also increased the risk that information shared with other health and social care professionals could be out of date and not reflective of a person's current care and treatment needs.

Most of the people told us they felt safe with the staff team. Relatives confirmed this. People's comments included, “The staff are very wonderful with him. I trust them so much. He is very safe with them” and “They are very nice people”. People told us they were supported to make choices and have control over their lives. Deprivation of liberty safeguards applications were made to the Local Authority appropriately in order to deprive people of their liberty in order to keep them safe.

All staff spoken with knew what action to take if abuse was suspected. Staff received safeguarding training. We spoke with the management team about two safeguarding incidents that had occurred in the home which were not reported to the local authority safeguarding team and CQC. We were not fully assured that the management team understood what constituted a safeguarding incident. It was clear from discussions with the management team they had not understood that these two events were of a safeguarding nature and should have been referred appropriately to the relevant outside bodies.

During our visit, the staff members we observed were kind and caring. We observed no inappropriate behaviour or practices.

There were safeguarding policies and procedures in place for staff to follow in the event of an allegation of abuse. The provider’s policy contained a ‘contact list’ for the Local Authorities to whom referrals should be sent. This contact list was not up to date and did not include contact details for all of the Local Authorities responsible for referring people to the service. However, incident records were maintained in respect of any accident or incidents including safeguarding events. Records showed appropriate action had been taken to investigate and protect people from harm.

Most people felt they were supported to manage some of the risks involved with their care such as risks of using the therapy pool, falls risks or choking. However, some people were not involved with reviews of their care and some people were not able to answer with clarity whether they felt supported to manage any care related risks.

Staff told us they had access to a folder in people’s bedrooms that gave them information on people's needs and risks. We reviewed this information whilst on site. We found this information was very brief and did not give staff a full insight into people’s care and treatment needs in order to help them manage any potential risks safely. People's care plans were not accurate or up to date. Some care plans lacked vital information about identified risks and care needs. This meant staff lacked adequate information about people's risks and safety requirements. This was reported to the management team to act upon.

It was quite difficult to complete direct observations of care, as majority of people received care privately in their own room and spent the majority of their time in their own bedroom. Only two people were observed in the communal areas on two different occasions. These people were left unsupervised. One of the people left unsupervised required specific risks in their environment to be managed. We found that action had not been taken to ensure these risks was minimised. Another person’s care file indicated that they were at risk of choking. Their care plan specified they were not to be left alone with access to food and drink as they required staff supervision. We visited this person’s bedroom and found cartons of juice and water on their bedside table.

People’s needs and risks were not adequately assessed or described, and staff had insufficient guidance on how to care for people and keep them safe. Appropriate risk management plans were not always in place for known risks. Where risks had been identified, we found they were not always managed effectively to prevent avoidable harm. Information on people’s needs and risks such as nutrition, skin, falls, behaviours etc was not clear or sufficient. When a person's needs had changed, care and risk management plans were not always updated to ensure staff had up to date information and guidance on how to provide safe care and treatment. Care and treatment records showed that people’s support was not always safely delivered or monitored. For example, risks in respect of clinical care provided in respect of a people's Percutaneous Endoscopic Gastrostomy (PEG) and Tracheostomy management were not always appropriately mitigated in accordance with best practice. Other risks, for example repositioning support to prevent pressure sore development was not always completed regularly to reduce the risk of a pressure sore developing. Risks to bowel health were not clearly monitored, as staff lacked guidance on people’s individual bowel patters to enable them to identify signs of decline that may require medical attention or advice. Environmental risks were not adequately monitored and addressed. A mobile oven was left on in a communal area on a 75-degree heat setting. This meant it was accessible to service users and visitors. It posed a serious burn and fire risk. Ceiling hoists identified as unsafe and unfit for use, were still in situ with no signage to advise staff not to use this equipment in support of people’s moving and handling needs.

People felt the home was clean and safely maintained. One person told us, "It is very clean and they keep my room spotlessly clean".

The management team told us that improvements to the environment had recently been made. Rooms had been redecorated and new flooring had been installed in some areas. There was an ongoing refurbishment and maintenance plan in place. We saw evidence of this.

The environment in which people lived was well maintained. People had the equipment they needed and the home was designed to meet people's needs.

There were no daily walkabout audits in place to check every day health and safety aligned with best practice. There were other processes in place to ensure the safety and upkeep of the premises, but we found that these had not been completely regularly or within the provider's own set timescales. For example, a health and safety audit was scheduled to take place every 6 months but this had not been completed since March 2023. The improvements identified in this audit had however been undertaken. During our inspection, a health and safety audit was started. Premises related issues were discussed at monthly management meetings with progress reported to the senior management team. A regular health and safety meeting had recently been set up to take place with internal colleagues. Environmental Health had completed a food hygiene visit in March 2023. The service achieved a rating of 5 (very good).

People told us there were enough staff on duty to meet their needs. People’s comments included, “Enough staff and come quickly”; “Plenty of staff”; “Lots of staff and there if I need them”. There was mixed feedback as to whether staff were sufficiently trained. People’s comments included, “Some are well trained and some are not. Some work well as a team”; “Mostly well trained but they [name of person] has had infections from the catheter” and “They all know what they are doing, they are brilliant”.

All of the staff spoken with told us there were enough staff on duty to enable them to meet people’s needs. Staff comments included, “Always enough staff”; “5 staff on duty today (in this unit), that’s enough”. There was a minimum of 10 staff on duty during the day and 9 at night. Staff told us they felt well trained and supported in their job role.

During our assessment, we had no concerns about staffing levels. Staff were observed to attend to people's needs promptly.

In the absence of a formal tool to determine safe staffing levels, the service was based on two staff members per service user. In addition the management team, consisting of an operations manager and a deputy manager were also available to provide support. Leadership support was provided off site by the registered manager and provider. The provider had a regional support team which included human resources and health and safety. Mandatory staff training was provided with adequate completion rates. Nurses were also provided with training in specialist areas such as tracheostomy care and percutaneous endoscopic gastrostomy (PEG). Care staff had not received basic training in these specialist areas. Best practice guidelines indicate care staff should have basic training if support in these areas is provided outside of a hospital setting. We discussed this with the management team and the operations manager advised they would review this. We looked at staff induction, supervision and appraisal records. Records did not show that new staff members had completed an appropriate induction into the service and their job role. Staff had also not received regular supervision or appraisal to monitor and support good staff practice.

People told us the home was clean and said staff used PPE (personal protective equipment) when supporting them with personal care.

Staff had received training in infection control and prevention and were knowledgeable about the use of PPE and basic infection control procedures. They were also aware of what action to take if they contracted COVID or other infectious disease, such as inform the manager, isolate, take a test and do not return to work until they tested negative.

We observed ample supplies of PPE for staff to use to prevent cross infection. Care and nursing staff wore uniforms and were bare below elbow to promote good hand hygiene whilst providing personal care. This was good practice. Members of the management team were observed to not always be bare below elbow. This increased the risk of cross contamination should the members of the management team be called upon to support frontline care, for example in an emergency situation.

As part of our assessment we sought feedback from the Local Authority Infection Control Team. They advised they had concerns with the processes undertaken by the provider with regard to Occupational Health Screening. Occupational health screening enables employers to health check staff are capable and fit health wise to undertake their role. These concerns had been escalated by the Infection Control Team for further action. The provider did not notify CQC of these concerns. With regards to infection control practices and standards within the home, the Infection Control Team told us standards were good. Cleaning schedules were in place to promote standards of cleanliness. These records showed gaps but on the days we visited the home was clean and people confirmed this. An annual infection control audit was completed. Prior to our visit the last audit undertaken was in May 2023. During our inspection, an infection control and prevention audit was undertaken with a score of 93% achieved. Some minor improvement actions were noted but these were without clearly defined timescales or details of who was responsible for their completion.

People told us they received the medicines they needed. Records showed however people experienced poor medicines management and were placed at risk of avoidable harm. Best practice safety guidelines were not followed. For example, medicines that needed to be given at specific times (before or after food), were not always given at the right time. When medicines needed to be given with a specific time interval between doses, the actual time the medicine was given was not recorded. This increased the risk of people being given too much or too little of their medicine at any one time. Some people required their medicines to be given covertly, hidden in food or drink. Yet staff did not always have information on how to administer these medicines safely. Where people were prescribed ‘when required’ medicines such as painkillers, staff did not always have access to person centred information that advised them how and when to give these medicines. This meant there was a risk people may not get their medicines when they needed them. When people had their medicines given via a feeding tube (PEG), staff did not always have guidance on how to administer these safely. In addition, staff instructions did not always clearly advise staff to ensure the person's medicines were given via their feeding tube. This increased the risk of people being given medicine orally which placed them at risk of avoidable harm. Some people had medication allergies but information about these allergies was not always properly recorded or risk assessed. This increased the risk of people being given a medicine they had previously reacted to.

Medicine instructions listed on some people's medicine administration records did not always match the prescription label on the specific medicine. We noted this was not always followed up by staff to determine which instruction was the correct one. It was also noted that staff signed charts to say some creams where applied when it was undertaken by another staff member. Concerns noted about medicines management were shared with the management team at the time of the visit.

Medication audits were completed, but these were ineffective at identifying medicine related issues and failed to identify the concerns found during our assessment. Nursing staff had received training in the medicine administration. However, we found nursing staff did not always follow the provider's safe medication administration policy or widely recognised best practice guidance on the safe management of medicines. This included safety guidance in respect of controlled drugs. Some of the provider's policies with regards to medicine management were not clear. For example, the medicines refrigerator was found to be outside of a safe temperature range. No action had been taken to ensure medicines were stored at correct temperatures to be safe to use. When we checked the provider's policy, we found that it did not detail what staff should do in that situation.