Moormead Care 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

We looked at five quality statements relating to safeguarding, involving people to manage risks, safe environments, safe and effective staffing, and infection prevention and control. We found 2 breaches of the legal regulations related to the safe key question, including safe care and treatment and safe staffing. We saw risk assessments and care planning documents were in place and reviewed regularly. However, the information in both documents was limited which put people at risk of unsafe care and treatment. We found staff were in place, however there were not enough staff to meet people’s needs in line with their risk assessment.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Relatives we spoke with felt their relative was safe in the home and received safe care. One relative said, 'I have no concerns about safety, my relative's falls risk was dealt with when they moved in.' Most people we spoke with said they felt safe in the home, where we heard people did not feel safe, we discussed this with the registered manager and Provider. Relatives were updated by the home in the event of an accident or incident.

Staff told us they had received safeguarding training and said they would report incidents to the manager. Leaders explained their systems in place to check staff awareness of safeguarding through discussion in supervision sessions and team meetings

We observed people were not always safeguarded from risks in line with their risk assessment. We observed there was not always staff available in the communal area to support a person at risk of falling.

A Safeguarding policy was in place and an opportunity to discuss safeguarding was included in staff meetings. Incidents were reviewed and safeguarding incidents had been investigated appropriately. However, we were concerned safeguarding incidents were not always recognised and raised in a timely way. We found a safeguarding referral was made 6 days after CQC had contacted the provider, following the identification of a safeguarding concern within the service.

Relatives felt the risks around their relative were managed and when incidents happened these were investigated, and action taken to mitigate the risk of a further incident. One relative said ‘I have no concerns about safety, and they dealt with their fall risk when they went in.”

Staff we spoke with said they were not always involved with developing care plans and risk assessments for new people coming into the home. We heard care plans and risk assessments were completed by non-clinical staff. The provider said they discuss risk assessments and care plans with nursing staff and the nursing staff have their own files for clinical care. Staff said the information in care planning documents was conflicting; however, the same staff said they have updated conflicting information when identified.

Risks to people were not always well managed. For example, we found pressure care devices had not been set up correctly in line with the manufacturer's instructions to prevent damage to people's skin integrity. We raised this with the provider on the day who acted immediately to amend the settings accordingly.

We saw care planning documents and risk assessments were regularly reviewed. However, these reviews were not always effective because they did not pick up the concerns we found in this assessment. For example, we looked 6 people’s care plans. We found care plans and risk assessments did not always include good levels of detail or had conflicting information about how people were supported with their health conditions. Information about pressure ulcer care and bed mattress settings was not clear for staff to then follow. Catheter care information did not include information about signs of infection for staff to be aware of. The registered manager made improvements to this information during the assessment process for some people. We found audits of pressure mattresses take place but were not effective because the audits did not include the weight the mattress should be set at. We saw amendments had been made to the pressure mattress audits on our second on-site visit to the home.

People we spoke with said they liked the staff, but felt staff were sometimes rushed. Relatives felt there was enough staff. One relative said, ‘staff are responsive and respond quickly to the buzzer.’ Another relative said ‘[There is] always someone around and they pop in to see if they are ok. The odd time they might wait for a carer but generally it is not a problem, they never say it’s a problem.’

Staff knew the action to take to maintain a safe environment. Most staff we spoke with felt the home provided a safe environment. One member of staff felt there were issues with getting some things fixed in the home in a timely way. Staff we spoke with said they had received fire training and information about how to use fire safety equipment. Leaders said they make sure actions are taken to make improvements when they become aware of any issues.

We saw the home was clean and free from trip hazards. However, people could have been placed at risk of harm because doors to areas of risk, for example the sluice room and the laundry room where chemicals were kept, were not locked. Oxygen cylinders were also not secured safely in line with national guidance. We spoke with the leadership team about this and found these shortfalls had been rectified during our second onsite visit.

Audits were in place for routine health and safety checks. For example, leaders reviewed window restrictor checks monthly, emergency light checks monthly, fire extinguisher checks and conducted weekly management audits. However, these checks had not picked up the shortfalls we identified around oxygen storage and sluice room safety.

People we spoke with said they liked the staff, but felt staff were sometimes rushed. Relatives felt there was enough staff. One relative said, ‘staff are responsive and respond quickly to the buzzer.’ Another relative said ‘[There is] always someone around and they pop in to see if they are ok. The odd time they might wait for a carer but generally it is not a problem, they never say it’s a problem.’

Some staff we spoke with felt there was enough staff in the home to support people. Other staff felt there were times when they were rushed, for example on a weekend, or when new people have moved into the home. Some staff also reported they did not have opportunities to take breaks during their 12-hour shifts. Staff said they have received training and have supervision.

We observed at times there was not enough staff available to ensure identified safety measures could be maintained; for example, we saw people were left alone in communal areas despite the need for one staff member to be available in communal areas when in use. People were not always supported by staff who had an adequate understanding of the risks around dysphagia (i.e. difficulty in swallowing). For example, we saw a person, who required food to be blended, was provided with a high risk food. We spoke with the staff member who confirmed they had not had the relevant training to know which foods were safe for a person with difficulty in swallowing. We also saw staff were on the phone at the same time as administering medication.

Records showed staff had completed mandatory training; however, we found some staff did not have appropriate training to understand dementia and complex behaviour despite there being some people in the service with dementia and complex behaviours. Leaders used a dependency tool to help understand staffing requirements. However, the staffing levels in the service did not appear to take into consideration people’s individual needs and requirements. For example, we saw people were identified as having the same amount of time allocated for mealtime support, personal care and pressure care, irrespective of their individual needs.

Relatives spoke positively about the cleanliness of the home. For example, relatives told us 'The bathroom and lounge are clean and tidy, and their bedroom is clean. We were also told ‘The home is extremely clean.”

Leaders told us they complete infection control audits, and they monitor staff for correct use of Personal Protective Equipment (PPE). Staff told us how they follow systems in place to reduce the risk of infection, but the sluices were not always working efficiently.

We saw the home was clean and free from odours. However, we noted during our first on-site visit to the home there was a risk of infection to people because we saw staff wearing PPE items in communal areas after coming from personal care support. We did not observe this practice happening on the second visit to the home.

Staff training records showed they had completed infection control training, and an infection prevention and control policy were in place. Systems were in place to reduce the risk of infection. For example, infection prevention and control audits were happening in the home, however these audits were not effective and had not identified the same concerns as we had around staff wearing PPE in communal areas.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.