Maristow Nursing Home

The provider did not have a proactive and positive culture of safety. They did not have an overview of incidents and accidents, which meant not all were appropriately investigated or reported. This did not ensure people were always safeguarded and lessons learnt were adopted.

The environment was not well maintained and there were aspects which were not safe. This included excessive hot water from hand washbasins, unsecured cleaning substances and a hot water urn accessible to people. Leaders confirmed they had taken action to address these concerns, following our inspection. There was stained, worn flooring and chipped paintwork throughout the service, which compromised good infection control practice.

Medicines were not always safely managed. This included the management of topical creams, homely remedies and covert administration.

Quality auditing systems were not effective as shortfalls found at this inspection had not been identified. Some audits had been inaccurately completed, which meant leaders could not be assured their auditing processes were fit for purpose. Record keeping was disorganised and did not clearly demonstrate management actions. For example, there nighttime audits were not documented and there were no action plans for fire safety works or the refurbishment of the building.

There were enough staff, who were knowledgeable about people’s needs. Staff received training to do their job effectively and received informal supervision. Staff were recruited safely.

People were assessed before moving to the service to ensure their needs could be met. There was good partnership working and people had access to a range of health and social care professionals. People were encouraged to remain healthy and their rights to independence, choice and control were promoted. Staff asked people for consent before undertaking any care intervention.

People were treated with kindness and compassion and their privacy and dignity were promoted. People were treated as individuals and their preferences were supported. Staff responded to people in a timely, attentive manner. People were encouraged to go out and remain part of their community and have visitors when they wished. Staff were well supported and worked well as a team.

People knew how to give feedback about the service and were confident they would be listened to. People’s communication needs were assessed and supported. Leaders worked to reduce health and care inequalities and reduce discrimination. There was a diverse workforce, which was promoted and embraced.

Leaders were passionate about the service, and its values and culture. They strived to provide a relaxed, comfortable home for people, based on individualised care. Staff understood their roles and responsibilities including raising concerns and poor practice if required. Leaders had developed good partnership working and established relationships had been built.

We identified two breaches of the legal regulation in relation safe care and treatment and good governance.

We have asked the provider for an action plan in response to the concerns found at this assessment.