Archived: Nutbush Cottage

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 care was not provided in a safe way as systems to safeguarding people from abuse were not effective. The risks associated with people’s care were not managed in a safe way and people were not routinely supported by people who knew them well. Whilst there needed to be some improvement in the management of medicines, people received their medicines as prescribed. During our assessment of this key question, we found concerns around the management of people's incidents and accidents and the risk associated with their care. We found concerns staff did not have the skills, knowledge and support they required. We found people were not always being protected from the risk of abuse. We found staff were not always recruited safely. These were breaches of regulation. You can find more details of our concerns in the evidence category findings below.

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.

Staff and leaders did not recognise the importance of reporting and reviewing incidents to ensure lesson were learnt. During our inspection we spoke with a number of staff members who informed us of incidents where people had been anxious and distressed. A review of records showed these had not been reported or recorded within people’s daily notes or on the provider's system. When asked why information in relation to incidents had not been reported one staff member told us, “It’s just [person], it’s just the way it is.” The leadership team had not ensured staff understood their responsibilities in reporting and analysing concerns. We spoke with the nominated individual regarding the processes they had in place to guide staff in reporting concerns. They told us, “I think maybe they [staff] just see it as part of their personality. If I saw staff not responding then I would tell them, and I’d expect the manager to do the same.” This did not demonstrate an effective and established approach to ensuring incidents were reported, monitored and learnt from.

The provider's processes had failed to identify shortfalls in staff practice. Incidents when people experienced anxiety were not always recognised or reported. There was no analysis of these incidents or changes made to people’s care to minimise the risk of concerns happening again. This meant people continued to experience periods of high anxiety which compromised their safety and well-being.

People’s care was not always planned in a collaborative way. Whilst people’s care plans were reviewed monthly, there was limited evidence to show how the majority of people were involved in this process. Care plans stated the majority of people responded negatively to being involved in the monthly reviews. However, there was no evidence that different methods of communication were used to support people with this process. This was of particular importance as the majority of people living at Nutbush Cottage had limited verbal communication.

Staff told us they were aware of people’s care plans and how to support people in a safe and consistent way. However, staff were not always able to share information and knowledge regarding how to keep people safe and the processes in place.

Professionals involved with the service told us they were not always kept updated in relation to people’s care and any changes impacting them. This meant concerns regarding people’s safety and wellbeing were not always known to enable professionals to provide the support people may require.

Processes for reviewing people’s needs and ensuring information was shared with staff were not effective. Whilst the provider had some systems in place such as monthly reviews of care plans and daily handovers of information, the information recorded and shared was not always meaningful and did not provide a good picture of how a person had been, what had gone well and how people had responded to different events had been taken into account. This led to people not receiving personalised approach and meaningful support that recognised their individual needs.

People were not protected from the risk of abuse as staff failed to report injuries people had sustained. Prior to the inspection we received evidence of a person who had sustained injuries which had not been reported to the local authority or CQC. This meant there was a risk the person had not received the care and treatment they required either for their injuries or to minimise the risk of them happening again. In addition, we found systems to protect people from the risk of financial abuse were not robust. Relatives and people's representatives told us they were not confident the whole staff team had the skills required to keep people safe.

Staff and leaders had failed to recognise and report safeguarding concerns to the local authority in line with their responsibilities. Whilst staff had completed training and were able to describe what action they should take to report safeguarding concerns, evidence showed this guidance had not been followed. The provider told us they reported any concerns they were made aware of and encouraged staff to do the same. However, we identified a closed culture within the service where staff were not willing to speak openly in relation to how one person had sustained significant injuries. We asked one staff member about safeguarding concerns regarding staffing which had been reported to us. They told us, “I can’t say anything. I saw how staff were treated when they spoke out before.”

We saw staff did not always keep people safe from avoidable harm. When one person was distressed and highly anxious staff did not ensure they were aware how close they were to others. This was despite staff being aware of recent incidents of this nature. This put people at risk of anxiety and potential injury. Although risk assessments were in place in relation to this, these lacked detail and we observed they were not followed by staff.

The provider had failed to ensure robust processes were in place to protect people from the risk of abuse. In addition to the lack of reporting, we found concerns regarding people’s finances were not identified or investigated. Transactions seen on receipts for one person showed purchases which were unusual for them to make. These had not been picked up during audits undertaken by the management team. Finance records did not require staff to sign for transactions, which meant a thorough investigation could not be completed by the relevant authorities. Following the inspection the registered manager told us they had changed the system used to monitor people’s finances to make the process safer.

People were not supported to manage risks to their safety and well-being. Two people continued to experience anxiety on a regular basis. However, staff we spoke with were unaware of how to support them and had limited guidance to refer to. In addition, guidance in relation to one person’s mobility was not always followed and staff were not aware of how to support them when they were walking on uneven ground outside. We heard examples from relatives and representatives regarding incidents which they felt had left people in an unsafe situation.

Staff were not always able to share information in relation to risks people may experience. One staff member was asked to support a person with complex needs they had never met before despite the person being in a highly anxious state. The staff member was not given the opportunity to read the person’s risk assessments or positive behaviour support plan. They were therefore unaware of the guidance to give the person space which could have led to an altercation causing further anxiety to both parties. The staff member told us, “It would have been useful to have read [person’s] care plan.” The registered manager told us that several staff had completed training in positive behaviour support with the view of cascading this information to other staff. However, we found the staff members who had received the training were not supporting people at Nutbush Cottage at the time of our inspection and there was no clear plan how this knowledge would be utilised and shared.

We observed numerous instances where the lack of staff understanding and knowledge of people’s needs put them and others at risk. This included staff not knowing what may upset people. One staff member was observed moving a person’s possessions around in an effort to interact with them. They were not aware the person became anxious when their belongings were moved. We observed another occasion when a person attempted to advise a staff member to leave the door closed when another person was repeatedly slamming the door shut. The staff member did not acknowledge or follow this advice which led to increased agitation and put others at risk. This was a repeat of concerns identified at our last inspection where a person felt they needed to intervene as staff were unaware how to support people's needs.

Risk management processes were not robust. We found risk assessments and positive behaviour support plans lacked detail. This meant the provider had failed to ensure staff had the guidance they required to support people effectively. Two people’s care records indicated they did not like strangers in their home. Despite this being raised at previous inspections, there was no guidance in place on how to prepare people for visitors and no guidance given to visitors on how they should approach or respond to people. This lack of information increased the risks associated with people’s increased anxiety.

Staff and the registered manager told us they felt the environment was safe. The registered manager said, “We report maintenance on the system, and it’s sorted. It’s usually pretty quick.”

On the first day of our assessment, we found the gate to the property was not fully closing and we were able to enter freely. This was a concern as two people were known to be at risk of leaving without staff support. Staff did not appear to be aware of this issue and this was not recorded on any daily walkabout or handover sheet. There was no guidance regarding what additional steps staff should take to ensure people’s safety. The registered manager said they were aware and were awaiting an engineer. The gates were functioning safely during our next visit. In other areas we found the property was safe and relevant checks of equipment were made as required.

Daily walkarounds were completed by staff with the aim of recording and reporting any issues with maintenance or cleanliness. These records were then forwarded to head office for review. However, this process was not consistently completed. This meant there was a risk issues would not be identified and responded to in a timely manner. The provider was in the process of establishing a new electronic system which they hoped would increase consistency.

People were not always supported by staff who were familiar to them or had knowledge of their needs. This meant people’s support lacked consistency and was not always personalised. Relatives/representatives told us some staff knew people very well but expressed concern regarding the number of new staff/agency staff and the skills and experience they had. Comments from relatives/representatives included, “I do believe more experienced staff are needed to support the people that live within this house.”

Some staff told us they felt the use of agency staff within the home was detrimental as they were not aware of how to respond to people appropriately which on occasions caused anxiety. One staff member said, “I cannot cope like this; I cannot go on; there is just too much with [person’s name] and the agency as well. It makes it so hard.” As the rota was not reflective of the staff on duty we asked one staff member if they had regular rest periods following working long days. They said they felt this had improved. However, when asked how many days the staff member had worked in the past two weeks they informed us they had worked significantly excessive hours in the last 2 weeks. This presented a risk as people were being supported by staff who were fatigued.

We observed staff deployed did not always have a good understanding of the people they were supporting. We asked one staff member to tell us about the person they were working with for the day. They were only able to share very limited information including that the person enjoyed spending time on their iPad which they were using at the time. They were unable to describe what they used their iPad for, any of their other interests, their communication needs, family support or how they could interact with them.

Staffing was not always planned well which led to staff working a high number of hours. Rotas we were provided did not match the staff who were on duty. There was also a very limited number of drivers which meant staff needed to swap their roles with others from the providers supported living services for periods of the day. There were also occasions when people were unable to go out as no driver was available. Safe recruitment practices were not always followed. Of the four recruitment files we reviewed we identified concerns for 3 staff members such as references not being sought from previous employment in care services, unexplained gaps in employment and contradictory employment histories. This meant the provider was unable to assure themselves the staff employed were suitable for their roles. In addition, up to date information regarding agency staff was not available to the manager and staff. Of the 4-agency staff we reviewed information for, 2 did not have staff profiles available and the remaining 2 profiles did not show annual training had been completed. There was no system for ensuring staff new to working at Nutbush Cottage and agency staff were introduced to people in a way which minimise their anxiety. There was no evidence the 4 agency staff members we reviewed had received an induction into the service.

Staff told us they had completed infection prevention and control training and were aware of the different processes in place. One staff member told us, “It’s very important for everything to be clean for them.” Despite these comments we found staff did not always follow this training.

Staff did not always follow infection prevention and control guidance to keep people safe. Staff told us due to people’s needs they were unable to keep soap and paper towels in the bathrooms. We observed a number of occasions when staff came from the bathroom and went directly to support people without washing their hands. When staff did wash their hands, this was in the kitchen sink and by using kitchen roll to dry them. In addition, we observed staff moving around the home wearing personal protective vinyl gloves before then going to support people with their personal care. When sitting at the outside garden furniture we found a large amount of animal droppings in close proximity to where one person had eaten their meal. In other areas we observed the house to be clean and tidy.

Processes within the home had failed to identify areas of concern in relation to safe infection and control practices. There was no set processes for staff and people washing their hands following using the bathroom. Daily walk around sheets had failed to identify the animal droppings observed by the garden furniture which appeared to have been present for some time. In relation to the general cleanliness of the home, a cleaning schedule was in place which was followed by staff with tasks completed on a regular basis. Staff had access to personal protective equipment as required.

One person told us they felt staff were aware of the support they required with their medicines. They told us, “They seem to know how to do it. I’m not worried about it.” However, our observations found that although regular medicines were administered safely, gaps in staff knowledge regarding as and when required medicines may put people at risk.

We spoke with staff who had completed training in supporting people with their medicines. One staff member was not aware of a person’s need for rescue medicines and when this should be administered. In addition, they told us that although they had partially completed the training they were not yet fully competent in its use. This was of concern as they were the only staff member on duty who had received medicines training. The registered manager told us the staff member had fully completed the training and assured us they would discuss this in full to ensure the person's safety.

Staff medicines competency checks did not provide assurances that staff were aware of their responsibilities. Where staff responses to questions needed to be sought, these answers were pre-populated on the competency assessment. This meant all response were identical and it was not therefore possible to see how each staff member's competence and understanding had been judged. During the second day of our inspection one person had been supported with PRN (as and when required) medicine due their distressed behaviour. This was not recorded on the person's records for several hours which meant there was a risk of further administration due to staff not being aware. A review of medicines records showed people received their medicines in line with their prescriptions. Medicines were stored safely and stock balances matched people’s medicines administration records. There was a list of staff signatures in place and medicines were returned to the pharmacy when needed. Where people required PRN medicines (as and when required) guidance was available for staff to follow.