High Lea House

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems were not in place to ensure information from incidents, monitoring, feedback, and day‑to‑day practice was routinely reviewed, analysed, and acted upon.

Repeated incidents, including falls and accidents, were not reviewed to identify themes, trends or emerging risks. For example, a person experienced multiple falls over several weeks, there was no evidence these incidents were analysed or actions were taken to reduce the risk of recurrence prior to a significant deterioration in their health. This showed the provider did not learn from incidents to prevent future harm.

Feedback from people and relatives was not used to make improvements. Concerns regarding cleanliness had been raised by a relative but had not been resolved over time, this showed a lack of learning from complaints or informal feedback. People we spoke with had expressed wishes for more activities, community access, and choice, and this did not result in changes at the home.

Safeguarding concerns were not consistently recognised or reported, and required notifications had not been submitted to CQC. This limited opportunities for external learning and oversight and demonstrated poor understanding of safeguarding responsibilities.

The prolonged absence of a registered manager and insufficient leadership oversight significantly undermined the service’s learning culture. There was no evidence of management review, sign‑off, or assurance to confirm learning had taken place following incidents, concerns, or feedback.

The provider did not 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 services. Changes in people’s needs were not always recognised or acted upon. Systems to identify and escalate risks were not effective. People had not been clinically assessed to determine the reason for monitoring, and there was no evidence of timely referral to, or review by, healthcare professionals. This demonstrated a lack of clear and effective pathways to external clinical support.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control.

People were not always safeguarded from the risk of harm. We identified injuries such as bruising and wounds which were not consistently escalated or shared with relevant partners. Accidents and incidents, including falls, were not routinely reviewed to determine whether safeguarding action was required. This meant opportunities to protect people from further harm were missed. The provider had not submitted required safeguarding notifications to CQC, including notifications relating to injuries and deaths. This reflected a lack of understanding of safeguarding responsibilities and limited external oversight.

Relatives reported a lack of reassurance about how risks were managed, including how staff responded when people refused medicines or chose to spend time alone.

The prolonged absence of a registered manager and ineffective governance systems meant there was no consistent management oversight, review or learning from safeguarding concerns. This prevented safeguarding systems from being embedded into day‑to‑day practice.

The provider did not demonstrate a proactive safeguarding culture that ensured concerns were identified, escalated, reviewed and learnt from, leaving people at continued risk of harm.

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.

Risk assessments were not always personalised or based on individual discussion, which limited people’s choice and involvement.Some monitoring arrangements were applied using a blanket approach, without clear evidence people had been consulted or agreed. People’s preferences were not always considered, and care records did not consistently support shared decision making. For example, during the night all people had checks. This was not assessed on people’s needs or individual preferences. For example, during the night all people had 2-hourly checks. This was not assessed on people’s needs or individual preferences. Relatives were not always involved or reassured about how risks were managed, including responses to medicine refusals or changes in people’s routines.

The provider did not consistently demonstrate a person‑centred approach to working with people to understand and manage risks, which limited people’s involvement and choice.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We identified environmental cleanliness and maintenance issues. For example, 1 person’s bedroom sink and fittings were visibly dirty, and a downstairs bathroom had missing tiles and a damaged door frame. The provider had not identified these issues, which increased the risk of infection and injury.

The provider’s fire safety arrangements did not assure us people would be kept safe. They had installed a stair lift as the built-in lift could not be repaired. There was no associated risk assessment, and Personal Emergency Evacuation Plans (PEEPs) did not clearly explain the stair lift should not be used in the event of a fire. Advice from the fire service confirmed this would be unsafe. This placed people at risk during an emergency evacuation.

Equipment used within the environment was not always managed safely. A pressure mat was in use in one person’s room, but there was limited information to demonstrate how often this would be cleaned and checked.

People told us they would like to see improvements around the home, this included feeling more secure in the garden. One person told us, “The home needs a secure garden”.

Whist improvements had been made to the environment since our last inspection, further improvements were required.

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. Gaps in leadership, oversight and staff competence increased the risk that people did not receive safe, consistent or well‑managed care.

The service had been without a registered manager for over 12 months. This significantly affected staffing oversight, supervision and the ability to ensure staff were supported, competent and working in line with regulatory requirements. The nominated individual, who was acting in a management role, did not demonstrate sufficient understanding of regulations or legal responsibilities, which limited effective leadership and direction for staff.

Staff did not consistently demonstrate the skills and knowledge required to manage risks safely. For example, where a person’s blood sugars were tested before meals, blood sugars were recorded above safe guidance. Records did not show the escalation staff had taken. We could only be assured as the district nurse went in daily to administer insulin and would check the sugar levels. We were not assured staff were effectively supported to identify deterioration in people’s health or know when to involve senior staff or external professionals.

Staffing arrangements during daily routines did not always protect people’s safety. At lunchtime, there was limited staff presence to observe people while eating, and staff interaction was minimal. The provider could not demonstrate staff were consistently competent, well‑led or effectively supervised to ensure people received safe and appropriate care

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not consistently ensure effective infection prevention and control practices were in place to reduce the risk of infection and protect people’s health and safety.

We identified cleanliness and environmental hygiene concerns. For example, 1 person’s bathroom had missing tiles and a damaged door frame. These issues had not been addressed in a timely way and increased the risk of infection. Arrangements for cleaning were not fully effective. A relative raised concerns about the cleanliness of their family member’s room, including food crumbs on the floor, which they said had not been resolved despite being raised previously. The provider did not schedule cleaning cover on Sundays, which increased the risk the environment was not maintained to an appropriate standard.

During observations of care, staff were seen wearing gloves and aprons when serving food, which was positive.

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.

Staff did not always store medicines securely. One person’s insulin was found stored on top of the medication trolley. This increased the risk of people accessing it and causing themselves harm. Although staff told us insulin was administered by district nurses, the provider remained responsible for ensuring safe storage within the service.

Protocols for as required medicines (PRN) were not effective. Some lacked essential information to guide staff on when medicines should be used, how people’s needs should be assessed, and how to monitor and manage people after administration. For example, 1 person was prescribed PRN laxative medication. The protocol was blank and only had recorded the name of the medication and ‘Constipation’. This increased the risk it may not be given safely or appropriately or effectively monitored.

Records relating to PRN medicines were not completed following NICE guidance. We found medicines, such as paracetamol, had been administered but the reason for administration was not recorded. This limited oversight and reduced assurance that medicines were effective and being used to meet people’s needs safely.

Care plans relating to medicines were not always accurate or up to date. For example, one care plan stated a person should receive omeprazole before breakfast. However, this medicine was no longer prescribed or recorded on the MAR chart. Diabetic care plans were generic and identical, and included instructions such as monitoring for changes in blood sugar without providing baseline information or monitoring requirements. This meant people were at increased risk of unsafe management of their diabetes.

Oversight of medicines management was poor. There was no effective system to audit medicines, review errors, or identify learning. The prolonged absence of a registered manager and lack of managerial oversight meant unsafe practices were not addressed in a timely way.

Medicines systems were not sufficiently effective to ensure people received their medicines safely and accurately.