Merle Boddy House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to safe care and treatment including medicines management and safeguarding people from the risks of harm or abuse.

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.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. There was a lack of reporting systems in place to ensure risk and adverse incidents were reported to external stakeholders, including the Local Authority and to CQC. This did not ensure people were protected from the risk of harm. Staff and leaders were not reviewing and reflecting on events within the service to reduce the risk of reoccurrence.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. We identified the level and quality of monitoring of people’s care and support needs, particularly welfare checks overnight varied. This information was not always recorded in real time, and not all staff completed actual checks of people, instead relying on checks via a video monitor, therefore not actually checking on their welfare. People’s care records did not make timing and expectations around welfare checks clear resulting in the inconsistencies we found.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately. Staff and leaders were not recognising where incidents and events within the service met the threshold to be reported to the Local Authority Safeguarding Team to protect people from harm and abuse. A lack of onward reporting was not protecting people or upholding their human rights. Standards of recording of incidents and subsequent internal investigations were poor.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People’s care records lacked detailed information to ensure staff were fully aware of risks and historical information to enable them to protect individuals from harm. Risk mitigation and onward reporting following incidents was poor. We identified people living with specific medical conditions, or taking certain medications did not have corresponding risk assessments in place to ensure staff knew how to safely meet their needs.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The care environment contained size and layout limitations impacting on the suitability to meet people’s changing, longer term care needs. People’s bedrooms contained limited floor space if equipment needed to be used in the future, and some people were reliant on being able to continue to safely use the stairs to access their bedrooms, as all the ground floor bedrooms were occupied. However, we found the service was well maintained and had recently had refurbishment works to the kitchen to make this more accessible for people.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. We identified concerns in relation to the level of staff in place overnight to meet people’s needs in the event of an emergency, such as a fire. With 2 staff on shift at night time, there would not be sufficient numbers of staff to support an evacuation and monitor people once outside. We identified shortfalls in staff training and understanding of people’s needs, particularly where people were living with dementia. From reviewing staffing rotas, overall there were sufficient numbers of staff during the day.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Staff wore their own clothes, and we observed they often completed hands on care tasks, while not being bare below elbow to aid hand hygiene and reduce the risk of the spread of infection. However, we found people lived in a clean and well-maintained care environment and were encouraged to help keep the service clean and tidy, particularly their own bedrooms.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. We identified significant concerns in relation to medicines management practices in place where people experienced constipation. As required (PRN) medicine protocols were poor, and there was a total lack of bowel monitoring within the service to ensure where people were taking medicine to manage constipation, this was working effectively, or staff were able to identify and escalate concerns to the GP as needed. We also found inconsistencies in recording when PRN medicine was given, placing people at risk of harm.