Hoyland Hall Residential 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

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 required 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 people’s safe care and treatment; the ways people’s medicines were managed safely and ensuring action was taken to address safeguarding concerns.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Lessons learnt documents were used sporadically, and there was a lack of consistent learning. Accidents and incidents were analysed but trends and patterns were not consistently identified to minimise future risks.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The care planning system had the ability to produce a hospital pack based on people’s care plans and daily notes completed on the electronic system. However, some care plans were vague and not specific about people's needs and how best to meet them, therefore the hospital pack did not always contain the correct information.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. We found safeguarding concerns which had not been reported in a timely way. This put people at risk of harm. The provider took action to ensure people were safe. Staff told us they understood the safeguarding process and said they would take action to report concerns.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. Staff and leaders did not have sufficient oversight of Deprivation of Liberty Safeguards (DoLS) or any conditions attached to them. The provider took action to address these concerns and updated their records to gain an overview of DoLS and any conditions in place.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people's care were identified but not always managed to mitigate risks. One person’s care plan stated they required staff to carry out safety checks hourly during the day and 2 hourly at night to prevent pressure care related issues, maximise their comfort and ensure they had not fallen. We reviewed daily notes and found many occasions where repositioning had not been completed in line with their care plan. One record showed the person had only received 2 safety checks in a 24-hour period. Care plans lacked information regarding the safe use of equipment such as hoists. People’s care plans did not always have instructions about the size or type of sling which should be used or the loop configuration required to assist people to transfer safely.Another person had a care plan to address a medical need; however, this gave minimal guidance to staff because it did not specifically identify what staff should do. One person who had been assessed as requiring bed rails, had these in place without a cover. This posed a risk of entrapment and potential injury. The provider took action to ensure these risks were addressed.

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. We identified 2 large items of furniture which had not been secured to the wall. There was a risk of these pieces of furniture toppling over onto people who were mobilising around the home. We identified some fire exits which were compromised, with items stored in these areas which reduced space. We saw a portable heater in use, but no risk assessment was in place and was extremely hot to touch. This was in the lounge where staff were not always present, and people were at risk of falls. The provider took action to address these concerns.

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. They did not always work together well to provide safe care that met people’s individual needs. Staff were not always deployed effectively, and some communal areas of the home were left unattended. Staff told us they felt overwhelmed with not enough staff working with them. Staff told us staffing levels were never increased when people's needs changed. The provider had a recruitment system in place to help them select staff which were appropriate to work with vulnerable people. Pre employment checks had been carried out prior to them commencing employment at the service. The provider could not evidence staff had received all the necessary ongoing training to carry out their roles safely. For example, some people living at the home had conditions such as epilepsy and diabetes, but staff had not received training in these areas. Some people living at the service had a learning disability, but staff had not been trained in how to support people with a learning disability. Following our inspection, we received confirmation that some specific training had commenced.

The provider did not always assess or manage the risk of infection. We caried out a tour of the home and found people were not always protected from the risk and spread of infection. Some areas of the home were in need of a deep clean. For example, shower rooms and the kitchenette required attention and clean bath towels were stored inappropriately. The management team took action to address the cleanliness of the service.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The provider could not always demonstrate that people received their medicines as prescribed. Where people were prescribed medicines on an as and when required basis, often know as PRN, protocols were not always in place to ensure they were administered correctly. Temperatures were not taken of storage facilities where medicines were kept. One person was prescribed medication in the form of a patch but there was no documented evidence to show this had been rotated in line with recommendations. Stock balances for some boxed medicines did not tally with the medicines in stock. We raised these issues with the management team who took action to address them and commenced refresher training and competency checks with staff.