Nottingham Neurodisability Service Hucknall

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• 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

During our assessment, we have identified breaches in relation to safe care and treatment. We assessed 5 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, this meant the rating for this key question has changed to requires improvement. Not all people and those important to them felt the service was entirely safe. Some people we spoke with said they felt safe living at the service and knew how to raise concerns whereas others did not. Staff did not always understand their duty to protect people from abuse. When concerns had been raised, managers reported these promptly to the relevant agencies. Medicines were not always managed safely. This meant people were at increased risk of receiving their prescribed medicines unsafely. There were not robust infection prevention and control measures in place which meant there was an increased risk of the spread of transmissible infections. Risks relating to the environment and fire safety were not always well managed. The provider failed to take timely action on known issues. There were enough staff to support people with their physical needs. Managers reviewed staffing levels regularly to make sure there were always enough suitably skilled and experienced staff on duty. Staff were recruited and inducted safely.

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.

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.

We received mixed feedback about the safety of the service. Whilst most people and their relatives told us they felt safe at the service others told us they had concerns. For example, one person told us, “I do feel safe living here,” whereas a relative we spoke with said, “There have been incidents which does worry me, I don’t know what is happening when I am not there.” We also received mixed feedback relating to raising safeguarding concerns. Whilst some people and their relatives knew how and who to raise concerns to, others did not. This meant not all people felt empowered to raise concerns if they had them. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we saw staff had applied the suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

The registered manager understood how to respond to allegations of abuse. They had a process of how to investigate and keep people safe. The registered manager was reactive and responsive to the concerns we raised and sent in a detailed action plan to address the concerns regarding the culture. Staff told us that they had no concerns, but if they did, they were confident the management team would act appropriately. Staff we spoke with told us they would not hesitate to report concerns relating to abuse to the management team and advised if no action were taken, they would escalate their concerns to the provider. Staff knew where to find the safeguarding policy.

Whilst we saw most staff had positive relationships with people, we did observe staff did not always recognise incidents as safeguarding concerns which raised concerns relating to the culture of the service. We observed a person independently using a wheelchair to mobilise from one area to another, the person stopped and told the assessment team where they were going. Shortly after this a staff member approached the person and said in a raised voice, “Where are you going?” and then without waiting for a reply, began taking them in the opposite direction of where they wanted to go. Two other members of staff were present during the interaction alongside the assessment team and did not address the interaction or raise any concerns. The assessment team raised this immediately with the management team. We also observed staff did not always respect people’s right to privacy as we observed staff providing personal care to a person with the bathroom door open. The bathroom was situated off a main corridor with people, staff and visitors walking past. The door was only shut when the assessment team passed the door. This meant people’s right to privacy was not always respected which raised concerns regarding the culture of the service. We observed other staff speak to people kindly and many staff approached people respectfully.

If an allegation of abuse was made, there were appropriate policies in place to guide the staff team. Records showed that incidents were investigated and referred to the local authority safeguarding team if needed. Safeguarding concerns were investigated and reviewed monthly. Safeguarding concerns were discussed during handovers to inform staff. There was a designated safeguarding lead at the service. However, due to the observations it was not clear how effective safeguarding processes were as none of the staff present recognised the incidents as safeguarding concerns. We also found lessons were not always learnt following safeguarding incidents. For example, we reviewed a safeguarding incident where a person who was not able to safely leave the service alone, left the service alone during the night. Safeguarding records stated, night checks had been increased to ensure doors were locked. However, these were poorly completed, and several rooms and exits were checked by the same member of staff at the same time. This raised concerns over the quality of the checks being made which increased the risk of reoccurrence. Safeguarding contact information was accurate and available at the service. There was a safeguarding policy in place which was available to staff.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The environment in which people lived was not always safe. Whilst people we spoke with were unable to comment about the safety of the environment, as there were ineffective processes to monitor and act on known concerns, we assessed that people did not have a positive experience. A relative we spoke with raised concerns about the safety of the environment, “I reported some wires, they fixed it but did a bodge job.”

Staff did not always know how to monitor the safety of the environment. When staff did monitor the environment, timely action was not always taken. Staff told us they had picked up several of the issues we found during the assessment on a quality audit but had failed to rectify any off the issues. For example, a storage room was found to be open and filled from the floor to the ceiling with yellow hard plastic waste bins. These were not stored in an organised manner and appeared to have been thrown in to the room. This meant these items could easily fall from height and injure people using the service, staff, or visitors. The registered manager arrived in the afternoon and rectified the issue however no action had been taken before this. Staff explained the service was currently under refurbishment. However, staff failed to recognise the impact these works had on the fire safety at the service. For example, staff told us they had moved people from their bedrooms to temporary bedrooms whilst new flooring was being fitted. Staff failed to recognise they should have updated the personal emergency evacuation plans (PEEPs) for these people to ensure they could be easily located in the event of fire by the emergency services. During the assessment, staff could not locate one of the unit’s PEEPs folder’s containing vital information which the fire service would require to safely evacuate people from the building. This meant there was a risk there could be a delay in the event of a fire. The registered manager told us they recognised the shortfalls in relation to the environment and was responsive to our feedback.

The home was not safe in the event of a fire. We found some fire doors had been removed to allow for new flooring to be fitted, whilst most had been re-fitted these had not been fitted correctly and some fire doors now did not close. We also found one fire door to be propped against boxes which posed a falling risk to staff, people, and visitors. The registered manager took action to address the fire doors following our feedback. We observed masonry bricks in a communal shower room, this was addressed with staff during the morning but remained in the shower room until the afternoon when the registered manager arrived at the service. In the same shower room multiple brown stains were observed around the toilet, as staff were using the toilet as a sluice to empty bad pans and urinals. The toilet seat had been removed and wedged behind the toilet. This posed a risk to people. An office door was seen to be propped open, the inspection team closed the door as no one was in the office and it contained personal identifiable information in it. The door closed, we then observed staff attempt to open the door but were unable to as staff did not know the code or have a key to access it. It took over 25 minutes to open the door. Staff not being able to access rooms meant there was a risk people using the service may get trapped inside placing them at risk of harm. Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the health and social care executive.

Audits were not effective in ensuring timely action was taken to address issues found. Issues such as furniture not being fixed to walls had been identified in a quality audit but not addressed which placed people at risk of harm. We found processes for checking the security of the building were not effective as the assessment team were able to leave an unalarmed door and gain access from the garden to the main road without alerting staff. This posed a risk to people living at the service who are not able to safely go out independently. We found the processes to ensure PEEPs were kept up to date and in the correct location were not effective. For example, we found some PEEPs were not accurate and people were not located in the correct room. This meant there could be a delay in people being evacuated in the event of an emergency. Equipment was kept safe, by checks and maintenance. We found equipment had relevant safety checks to ensure they were safe to use.

We received mixed responses from people and their relatives about staffing. Whilst everyone we spoke with told us staff were kind and caring and responded to their needs, some people told us staff did not have time to chat to them which made them feel lonely. Relatives we spoke with gave mixed feedback about the number of staff on duty. A relative told us, “There seems to be plenty of staff, you can always find someone.” Another relative we spoke with said, “They are understaffed at times, but the team try their best.” Another relative we spoke said, they had concerns over the use of agency staff and felt they did not support their relative the way permanent staff did. All people and their relatives we spoke with said staff were kind and knew how to support them safely. A relative said, “Staff are responsive and very supportive.”

Staff told us there were enough people on duty and felt they were well trained to carry out their duties safely. A staff member we spoke with said, “I have had training, but I also learn on the job, get to know people’s complex needs.” Staff told us they worked well as a team to make sure people were supported safely. Staff told us they had regular opportunities to meet their manager on a one-to-one basis for supervision. These meetings gave them the opportunity to feedback any concerns or ideas they had.

We saw there were enough staff to provide support to people safely. Staff were deployed effectively around the building to provide support to people. We observed any nurse call bells to be answered promptly. We saw staff were suitably trained to complete their roles. Staff used moving and handling training to support people safely.

There were clear processes to ensure there were enough staff. There was a dependency tool in place which assessed how many staff were needed to support people safely. Staff had received suitable training to do their role. The management team ensured there were always suitably skilled staff working. Due to the complex conditions people lived with, specialist skills were required such as tracheostomy care and suctioning. Records showed staff were trained in specialist areas. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had also had a Disclosure and Barring Service (DBS) check prior to starting work at the service. These check the police database for convictions or warnings that may impact the staff members safety to work with people. The service employed registered nurses. The provider ensured nurses were registered with the regulatory body (The Nursing and Midwifery Council). The provider supported the registered nursing team to ensure they completed their revalidation process every three years to ensure their registration was maintained.

People were unable to tell us whether they felt the home was sufficiently clean. However, relatives we spoke with gave mixed feedback about the cleanliness of the environment. We found some areas of the home and equipment in it needed further cleaning. This meant people did not always experience care in a hygienic environment. A relative we spoke with told us, “There should be more cleaning.”

The registered manager was receptive to our feedback they acknowledged the standards on the day of our on-site visit had fallen below the expected standard. The registered manager was reactive to our feedback and instructed staff to rectify the issues. Staff we spoke with recognised the service needed updating to ensure it could be cleaned effectively. Staff explained the service was undergoing refurbishment works such as new flooring to ensure the floors could be cleaned effectively.

Areas within the home were unclean. We found a bathroom which was in use to be unclean and malodorous at several times throughout the day. We observed a large pile of laundry on the floor in a communal bathroom which included towels and underwear. We observed staff to pick this unclean laundry up without wearing sufficient personal protective equipment (PPE). This was not in line with best practice guidance and increased the risk of the spread of infection. We observed a cinema room which was being used as a storage room to be open for all people and visitors to access to be unclean. There was a sink in the corner of the room where the taps had a build-up of limescale, this created an environment for legionella and other water-borne pathogens to accumulate. We observed a fridge in use for people using the service to be very unclean. We observed storage rooms to be disorganised with items being stored on the floor, this meant the rooms and equipment in it could not be cleaned effectively. We observed tiles to be falling off a bathroom wall which was in use, this meant the area could not be cleaned effectively. We also found a commode in a shower room which was rusty, this meant this could not be cleaned effectively. The rusty equipment was moved following feedback to staff. We did observe staff to wear PPE when supporting people with their personal care needs. This was good practice and in line with best practice guidance.

Processes in place meant there were not robust infection prevention and control processes in place. We reviewed documentation for the cleaning of specialist breathing equipment. Records demonstrated equipment should be cleaned weekly, we found records to be inaccurate. We visited the service on 5 June 2024; however, staff had signed to say they had cleaned the equipment on 8 June 2024. This meant there were limited assurances that the equipment had been cleaned. This increased the risk of harm to people. We found audits to be ineffective. Whilst audits had identified issues such as poor storage areas and unclean equipment, insufficient action had been taken prior to our inspection to improve the infection prevention and control standards. Poor infection prevention and control processes increased the risk of the spread of infection, placing people at risk of harm.

People did not always receive their prescribed medicines at the correct time. We found a person who was prescribed a medicine for severe pain and should have taken it every 12 hours, to regularly not receive this at the correct time intervals. This increased the risk of the person being in pain. People we spoke with told us staff did not always support them with the application of topical creams. A person we spoke with told us; they were supposed to have a cream applied twice a day but only received it once a day. We found other people who were prescribed topical creams had no record of application. This meant it was unclear whether people were receiving their prescribed medicines. A relative we spoke with also raised concerns about the application of topical prescribed creams. However, other relatives we spoke with told us they felt staff managed medicines well and when medicines errors occurred, they had been informed.

The management team told us they were aware of the issues relating to topical creams. However, they had not taken sufficient action to ensure practices relating to topical creams improved. Not all staff we spoke with were clear on the process of how oxygen should be prescribed. Some staff we spoke with explained the oxygen order form to be the prescription whereas other staff identified oxygen should be prescribed on the medicine administration record. Oxygen is a prescribed product therefore should be prescribed with instructions of when it should be administered, how much and the route in which it should be given. This increased the risk of oxygen being administered incorrectly. Staff were able to explain how they supported people to take their medicines safely. Staff we spoke with discussed in detail how they supported a person with diabetes with their insulin requirements and a person who required their medicines via a percutaneous endoscopic gastrostomy (PEG) tube. They discussed the support they provided and how they managed people’s medicines. Staff knew who to report medicine concerns to. They explained the incident reporting system and how they reported any medicine errors.

Processes in place meant medicines were not always managed safely. There were not always clear records of when staff had given prescribed medicines. For example, we found multiple records where it was unclear when topical creams were administered. We also found some medicines records held incorrect information relating to people’s allergy status. This was fed back to the management team who advised they would contact people’s medical teams to ensure any allergies were documented on the medicine administration record. We found oxygen prescriptions missing for some people and some people did not have detailed ‘as needed’ oxygen protocols in place. This meant staff did not have clear guidance relating to when they should administer oxygen. We found where staff had made handwritten entries there was not always two signatures in place. For example, midazolam a medicine which can cause drowsiness, had been transcribed with only one staff signature. This increased the risk of transcription errors, which placed people at risk of receiving their medicines unsafely. Staff had received training on how to administer medicines safely and had their competency assessed. Medicines were stored securely.