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Morley Manor Residential Home

Overall: Requires improvement read more about inspection ratings

Brunswick Street, Morley, Leeds, West Yorkshire, LS27 9DL (0113) 253 0309

Provided and run by:
W & S Red Rose Healthcare Limited

Report from 15 February 2024 assessment

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Safe

Requires improvement

Updated 23 April 2024

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. We checked to see if: There were effective systems, processes and practices in place to make sure people are protected from abuse and neglect. That risks were assessed, and mitigating actions put in place. There were appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that meets their needs. We reviewed 4 quality statements for this key question. We have identified breaches in relation to safe care and treatment and staffing.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning culture

Score: 1

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

Safe systems, pathways and transitions

Score: 1

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.

Safeguarding

Score: 3

People living at the home told us they were safe. People told us, "It’s alright here, they look after us and we are safe" ;"I feel safe because there are lots of people around" and "The care is alright and I feel safe because of the staff." Relatives told us, "[Person] is safe because the staff are lovely and have a really good bond with [person]."

Staff and the manager demonstrated a good understanding of people's needs and how risks are managed, as well as their responsibilities and duties to identify and report any safeguarding concerns

We did not identify any safeguarding concerns linked to staff's approach or delivery of care. When staff interacted with people, they did so in a caring way. We did not identify any safeguarding concerns linked to staff's approach or delivery of care.

There were policies and procedures in place in relation safeguarding people, and these were being followed by staff and management. However, we found there were gaps in staff's training in safeguarding.

Involving people to manage risks

Score: 2

Risks to people's care were managed well by staff, however risks assessments were not always complete or detailed. People told us, "The people here make me feel safe, there is no one I don’t like or don’t trust. I would talk to any of the girls about concerns, they are all pleasant and listen." Relatives told us, "[Person] can’t get out of bed now, this is only recent, [person] has an airflow mattress. [Person] is safe because they look after [them]."

Overall, staff demonstrated good understanding of how to manage risks linked to people's care. Staff told us they feel well supported by management and would feel confident in raising concerns about people's care to management. Staff demonstrated good understanding of risks and good practice while supporting people, such as during moving and handling people. Manager demonstrated a good understanding of people's needs and how risks are managed. However, we found that the level of detail provided by manager and staff about risks linked to people's care and how these were managed, such as behaviours that might be considered challenging to others, were not reflected in people's risk assessments and care plans.

Observation of staff's practice during inspection visit showed staff were mainly attentive and responsive to people's needs. We found risks to people's care were well managed and we did not identify any concerns about staff's practice, such as during support with moving or handling or nutritional support.

Peoples risk assessments were not always detailed or been updated when peoples needs had changed. The staff and manager where aware of how to manage peoples care, however these were not always documented in peoples care and risk assessments and are plans appropriately.

Safe environments

Score: 1

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

Safe and effective staffing

Score: 3

People told us, "I feel safe because there are lots of people around" and "The staff are all very good, you sometimes have to adapt your choices if they are busy but there are plenty of staff, they never seem short. There are plenty of staff knocking about. There are separate staff at 8pm who look after us during the night." People also told us they felt staff had the right skills to support them; one person told us, "I never, never, ever feel that they don’t know what they are doing." Relatives told us, "There seems to be the same staff, and enough on duty." Relatives also felt staff were well trained; "I have worked in care and I think they are well trained. They are really on it and the communication is good, proactive."

Staff indicated they feel well supported by management and did not raise concerns in relation to staffing levels. The manager told us how they assessed staffing levels using a dependency tool, they told us they monitored staff deployment everyday.

In our observations, we did not find concerns about staffing levels or staff deployment.

Staff training was not up to date. A considerable number of staff had not completed some training for example : safeguarding, fire safety and falls training. We found no evidence that people had been harmed however, the provider’s had not ensured staff had the required training. This placed people at risk of harm. This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The manager and nominated individual were in the process of taking action in relation to staff training. Staff were mostly recruited effectively however there were continued issues in relation to recording of staff references. We recommend the provider ensures safe recruitment.

Infection prevention and control

Score: 1

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines optimisation

Score: 1

Medication was continued to not be managed well. We found medication administration records either not in place or limited information required. We found people whom required medication to be hidden in their food or drink did not have appropriate documentation to ensure this was completed safely. We found one persons medication patch's were not been rotated in line with the manufacturers guidance. People did not have any medication care plans, for example: people who required certain specific medication. Evidence from inspection indicates that this demonstrates a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have not found people were harmed , however lack of medicines oversight had put people at risk.