Hayes Court

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 good. At this assessment the rating has changed to requires improvement.This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, including safe management of medicines.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff and leaders described how incidents, concerns and complaints were recorded, reviewed and used to support learning and improvement. Accidents and incidents were analysed to identify themes and actions were taken to reduce the risk of recurrence. Staff said they felt able to raise concerns and these were discussed during handovers and meetings.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were arrangements in place to assess people before admission and to coordinate care with health and social care professionals, including GPs and community services. These systems supported continuity of care and helped timely discharge from hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were protected from abuse and improper treatment, and staff understood their safeguarding responsibilities. People and relatives said they felt safe using the service. One relative told us, “I am confident that [my family member] is safe.” Staff knew how to recognise and report safeguarding concerns and worked with external agencies when required.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that people were only deprived of their liberty when there were legal authorisations in place to do so to keep people safe.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although people and relatives gave some positive feedback about support with risks, and care records included a regular review of risk assessments. We observed some unsafe practices, including inappropriate use of mobility equipment, and support equipment, such as Zimmer frames, not being kept accessible for people. We also observed that whilst people who were at risk of developing pressure wounds had the correct equipment in place, including pressure relieving mattresses, we found these were not always kept at the correct weight setting increasing the risk of pressure damage. These issues increased the risk of harm. Once we informed the manager of our concerns, they took immediate action to address the concerns identified and ensure equipment was used safely.

The provider 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 provider did not always ensure the environment was safe and well maintained. The premises were clean and spacious, and people’s rooms were personalised. However, we identified environmental risks that had not been recognised through routine checks. These included unalarmed fire exits and unrestricted upper‑floor windows, increasing risk of harm to people.

The provider 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.

The management team ensured there were sufficient staff on duty to meet people’s needs and ensure their safety. People and relatives felt there were enough staff and spoke positively about their approach. Staff said they worked well together and felt supported by their colleagues and managers.

The provider had a training programme in place to ensure staff completed their mandatory training. However, there was not an effective system in place to ensure this training was regularly reviewed to ensure staff stayed up to date with best practice guidance. The manager told us they were in the process of seeking a new training provider to provide increased flexibility in accessing refresher courses. The current training did not cover the statutory requirement to ensure all staff are trained in supporting people with learning disabilities and autism. The manager said they would ensure this training was offered under the new provider.

Recruitment practices were in place. This included an initial review of employees’ criminal records through the disclosure and barring service (DBS), but the provider did not have any systems to undertake further reviews and many of the staff had been employed for several years. The manager told us they had plans in place to introduce a regular review as well as an annual declaration process to ensure suitable staff were employed.

The provider did not always assess or manage the risk of infection.

The home appeared clean and people said staff usually used personal protective equipment appropriately. However, there was no completed infection prevention and control audit, and governance systems did not provide sufficient assurance that risks were being identified and managed in line with best practice.

The provider did not make sure that medicines were safe and met people’s needs, capacities and preferences.

The provider did not manage medicines safely, placing people at risk of harm. We found unsafe practices in the management of medicines, including unsafe handling and storage of controlled drugs. There were no protocols for medicines prescribed on an ‘as required’ basis, records did not accurately record what was administered for variable dose medicines, stock discrepancies meant not all medicines could be accounted for and body maps were not being used to record the administration site for transdermal patches that required rotation to reduce the risk of skin irritation.

Although immediate action was taken after our inspection to review practices around the management of controlled drugs, these serious concerns had not been identified through routine audits and put people at the risk of not receiving their medicines as prescribed.