The Magnolia 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 identified one breach of the legal regulations. We assessed a limited number of quality statements in the safe key question and found areas of concern. The scores of these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Though the assessment of these areas indicates area of concern since the last inspection, our rating for the key question remains requires improvement. Systems and process to monitor the quality and safety of people’s care and their living environment were not always effective or sufficiently robust, which placed people at risk of avoidable harm. The provider took action to improve the safety and welfare of people living with diabetes, which included seeking guidance from external professionals, and through the improvement of records documenting people’s care needs and treatment. Staff were not always confident in the effective use of the electronic medicine recording system in monitoring and supporting them to manage people’s medicines and treatment safely. Areas within the environment and some equipment was found not to be clean. The provider had identified some gaps in staff training in key areas, which were being monitored to ensure improvements were made. Audits were in place to monitor safeguarding concerns and to ensure Deprivation of Liberty Safeguards (DoLS) conditions were met. Systems and equipment were maintained to promote people’s safety, including gas, electrical and fire systems.

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.

Some people had been placed at avoidable harm as a result of neglect in the management and oversight of specific aspects of their care and treatment. People living at the service told us they felt safe. One person told us, “I feel 100% safe, there is always a member of staff about if you need them. Someone upstairs fell and the staff were all there instantly. I feel they would be there for me if I needed them.” We received mixed feedback from people’s relatives who told us their relative was safe, whilst some expressed concerns about the cleanliness of environment, which they believed could impact on safety.

Staff told us they felt the service was safe for people. Staff had undertaken training in safeguarding and understood how to recognise and report concerns.

We identified people were at risk of harm due to poor diabetic care and management which presented a significant safeguarding risk. We raised these concerns with the provider who took immediate action to safeguard people using the service. This included consulting with health care professionals who made some changes to prescribed medicines and the updating of people’s care plans in response to health care staffs advice. The provider raised a safeguarding concern with the local authority following our site visit in relation to the neglect of people living with diabetes. The provider appropriately shared information and reported safeguarding concerns with external stake holders.

Processes in place had not been sufficient or effective at ensuring staff had the skills to identify anomalies in people's blood pressure and escalate these to ensure people were safeguarded from risk of harm. For example, one person had displayed dangerously high blood glucose readings on 2 occasions within the last 5 days. Specifically, on the 9 May 2024 they tested over 29mmol/L, and on the 6 May 2024 they tested 28.2mmol/L. Records indicated that on both occasions staff did not follow safe diabetic management procedures. Records indicated staff did not seek medical advice, encourage the consumption of water, or complete blood glucose retesting to ensure administered insulin had been effective. Moreover, records indicated that the person was provided with food by staff shortly (10 minutes approximately) after these high readings were obtained. There was a safeguarding system in place, which included informing external agencies of safeguarding concerns. The providers audits and reports included monitoring safeguarding concerns, which included checks to ensure Deprivation of Liberty Safeguards (DoLS) conditions were being met.

People's and relatives involvement with risk management was mixed. A person told us, "I have a safety plan that allows me to have some independence." A relative told us, "I've never been involved, but would like to be."

Staff told us how they supported people to make day to day decisions about their care and help them make informed choices related to risk. We raised concerns about risk we noted in diabetes management with the provider. They acknowledged the care provided to some people had not been consistently managed and took prompt action to mitigate the immediate risk.

Staff were seen supporting people to move around the home safely.

The providers systems and processes for monitoring of risk were not always effective. For example, blood sugar monitoring for people with diabetes was not consistently completed, and staff did not always respond appropriately when blood sugar readings indicated poor diabetic health. This put people at risk of harm. Risk assessment tools were used to understand people’s need and identify risk. However, these were not always completed effectively. Falls risk assessments did not always include essential information about specific aspects of people’s health and wellbeing, which may impact on their mobility. For example, where people had undergone surgery for a hip replacement or the use of prescribed medicines.

People shared their views about the safety of the environment. A person told us, "I like the fact that the building is secure night and day."

We spoke with staff and asked them about their views on people’s safety and the environment. Staff mostly spoke positive about the environment from a risk perspective, but one staff member did describe the service as “plain, not much decoration.”

We noted a radiator cover was broken in a toilet. Records showed this had been reported and a replacement ordered. The potential risk had been assessed and determined to be low as the toilet was not used by the person and the radiator had been turned off.

Audits, including a daily walk around check were undertaken and where environmental concerns were noted these were documented and escalated to bring about improvement. For example, fencing had been requested to promote people's safety. Records showed systems and equipment were maintained and inspected by external companies to promote people’s safety, including gas, electrical and fire systems.

We received mixed feedback from people and their relative’s about the availability and skill of staff. One person told us, “There are times when it takes them a long time to answer the call bell. I just have to wait for whatever I need.” Audits of call bell response times viewed showed call bells were responded to promptly. A relative told us, “There is always a staff member in close vicinity when I visit.” Another relative told us, “I think the carers need more training,” and went onto describe how a member of staff did not follow safe protocols when supporting a person to empty their catheter. People and their relatives spoke positively of the kindness of staff. The availability of the manager both in person and by telephone was raised as an issue of concern for some people and their family members, and reference was also made to the high turnover of managers at the home. A person told us, “The staff are all nice.”

Leaders of the service described how they assessed people’s care needs to ensure there were enough staff to meet their needs. Staff told us they felt there were enough staff on duty and that they received the training they needed to meet peoples’ needs. A recent staff survey undertaken by the provider had highlighted staff wanted support with professional development and greater feedback on their performance and work. The provider in response had developed an action plan to address staff feedback which included a commitment for staff to receive a mini supervision and observations monthly.

We observed there were enough staff to meet the needs of people using the service. Staff interacted kindly with people and appeared to be comfortable with staff.

The training matrix viewed at the time of our site visit showed improvements were needed to increase the completion of staff training in some key areas to promote safety. For example, moving and handling and basic life support. Training was organised for staff in diabetes awareness and management in response to the concerns we raised. The provider’s quality monitoring report of May 2024 had noted improvements were required in both staff training and supervision. The report recorded that in response to these findings, the manager of the service would undertake an assessment of staff and had set a deadline for staff to complete e-learning. The provider had employed a lead training co-ordinator to support with meeting staff training needs and to develop learning processes such as staff inductions and competency assessments.

People’s relatives spoke of the service not always being kept clean. One relative told us, “There is usually a bit of a smell, and the communal toilets are usually filthy.” Another relative told us, “I do see cleaning going on, but the home does not smell very nice.” They went onto say, "the bathroom floor is tacky and needs replacing, but overall the room okay, sometimes smells or urine." People had shared their views about the cleanliness of the service within survey developed by the Provider, which indicated an overall positive score for cleanliness.

Staff via ‘CQC’s share your experience’ (on-line feedback form) had shared information of concern regarding the cleanliness of the service. Staff told us they wore Personal Protective Equipment (PPE) and worked as a team to ensure cleaning was completed. Staff said they were satisfied with the level of cleanliness at the service.

The service and equipment were not clean. Residue and dirt were visible on surfaces in multiple toilets. A used wound dressing was found on a staircase and dirty papers towels had been left in a bathroom. Some people’s toothbrushes were visibly dirty, and some mattress covers were stained and had a malodour. This meant people were not provided with a suitable clean living environment and were not protected from the potential spread of infection.

The provider had systems and process in place to monitor and review the cleanliness of the home. However, some of the audits had not identified the concerns we found during the assessment. A schedule for the cleaning of wheelchairs was in place and audited. The provider informed us replacement mattresses had been ordered.

People were mostly satisfied with the support they received with medicines. A person told us, “I was started on a new heart medication, and they explained it to me.” When asked if they received there medicine on time a person said, “I think so.” A relative told us, “I have often visited in the past and found the odd tablet on the floor, or on the bedside table.” The relative went onto say this could no longer happened as their relative no longer took medicine in tablet or capsule format.

Staff told us they preferred to use paper Medicine Administration Records (MAR)’s to record medicine administration. The provider had put into place an electronic monitoring system for recording medicine management, which staff said was cumbersome to use. We raised concerns around the safety of the digital system as well as safe disposal of needle sticks with leaders of the service. They acknowledged these shortfalls and took immediate action to implement additional monitoring to mitigate the risk.

The provider had a digital medicine recording system in place. However, staff were not always aware of how to use this effectively. For example, there were concerns that processes to identify where people's medicine patches had been applied and where blood glucose readings were stored were not robust to support people to receive their medicines safely.