High Lea House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to meeting responsibilities in sharing safeguarding information and governance. The home remains in breach of governance.

This service scored 50 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. We identified gaps and inconsistencies in assessments increasing the risk people’s needs were not fully understood or met.

Care plans and assessments were not always personalised or up to date. Essential assessments, including those relating to stair lift use and emergency evacuation, were missing or did not reflect known risks. This meant people were exposed to avoidable safety risks.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Care planning did not always reflect current guidance or individual clinical advice. One person’s care plan stated a GP had advised a normal diet due to weight loss. However, there was no evidence of this discussion or clinical instruction. This limited assurance that care was based on professional advice. Guidance for responding to behaviours of distress was not effectively implemented. Documents did not record patterns or triggers to be identified, and information was not used to review or adapt people’s care.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services. Systems for communication, coordination and escalation were inconsistent, which limited people’s access to timely and joined‑up care. Information sharing within the service was not reliable. Care records contained conflicting or inaccurate information, which affected staff’s ability to work together and provide consistent care. Emergency planning arrangements did not reflect clear, agreed approaches with external advice, which increased risks during emergencies. The local authority told us they had provided significant additional support to the provider. However, despite all the support provided they had not seen any improvement in the service.

Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. People were not consistently supported to manage their health conditions and maintain their wellbeing. Systems to assess, monitor and respond to people’s healthcare needs were not always effective.

Care planning did not always reflect people’s individual health needs or provide staff with clear guidance. For people living with diabetes, care plans were generic and not person‑centred. Plans did not include information about individual blood glucose targets, how changes in blood sugar levels presented for the person, or clear actions staff should take in response. Although staff were instructed to monitor for signs of changes in blood glucose levels, there was no evidence of blood sugar monitoring or of guidance to support staff to do this safely. In one case, a care plan stated a GP had advised a normal diet due to weight loss. However, there was no evidence to support this discussion had taken place.

People we spoke with told us meals were, ‘ok’ and they did have options and opportunities to change their choice to match their preference.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and

consistent, or that they met both clinical expectations and the expectations of people themselves.

Systems in place did not ensure information was reviewed, acted upon or used to support continuous improvement, which placed people at risk of poor outcomes. Although monitoring tools were used, including fluid charts and incident records, there was no effective oversight or analysis to identify changes in people’s needs.

Outcomes for people at risk of falls were not effectively monitored. Repeated falls were recorded but not reviewed to identify patterns or escalating risks. In one case, a person experienced multiple falls over a short period without a formal review before their condition deteriorated and they required hospital admission. This demonstrated missed opportunities to improve outcomes.

There was no evidence outcomes were reviewed or learning was used to reduce recurrence of harm or improve people’s safety.

The prolonged absence of a registered manager and lack of effective oversight meant care was reactive rather than proactive, and the provider could not demonstrate people’s outcomes were consistently reviewed or improved.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. Systems to assess and support people’s capacity to make decisions were not always effective.

People’s capacity was not always clearly or accurately recorded. Care records contained conflicting information about people’s ability to understand and make decisions, which created uncertainty about how staff should support people and obtain consent. This increased the risk care and treatment may not be delivered in a lawful or person‑centred way.

Deprivation of Liberty Safeguards (DoLS) was not well understood or managed. Records showed applications had been submitted unnecessarily, indicating a lack of clarity about when authorisations were required and how they should be reviewed. Some documents we reviewed to support people’s wishes and treatment decisions were not valid or correctly completed. This meant there was a risk people’s preferences for their care and treatment may not be recognised or followed appropriately.

We identified poor practice in decision‑making. One person had been asked to sign a declaration stating the provider would not be responsible for any harm if they chose to go out independently. This approach is not consistent and does not support lawful consent or duty of care.