Halmer 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 requires improvement. At this assessment the rating has remained requires improvement. There had been improvements since the last inspection, and the provider was no longer in breach of regulations. However, there were still some areas where improvements were needed to ensure people received safe care.

This service scored 59 (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.

The service showed a developing learning culture, where staff took steps to reflect on incidents and improve care. Accidents and incidents were recorded on the computer system and handed over to the next shift, helping maintain continuity. These were also reported to the manager, allowing for oversight and opportunities to learn.

Medicine errors were documented and reviewed by the manager, which supported accountability and encouraged improvements in practice. Care plans were updated following incidents to help ensure people’s needs continued to be met.

The new manager made efforts to involve family members in discussions after incidents, aiming to understand their views and agree on the best way forward. The manager was new to the service and had begun reviewing systems and processes. It was recognised that time would be needed to fully embed learning and ensure that reflective practice became a consistent part of the service’s culture.

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.

Staff had worked effectively with the Clinical Assessment Service (CAS), a local out-of-hours alternative to NHS 111. CAS gave nursing and residential care homes direct and priority access to advanced practitioners and doctors who understood the local health and social care system well. Staff said they felt supported by CAS and found the service responsive. This joint working helped people stay in their care setting and reduced the need for hospital admissions, supporting safer and more consistent care.

People were happy staff supported their healthcare needs. They told us any changes in their care needs as a result of hospital visits were effectively communicated with them and implemented immediately.

Care plans were in place and included key information about people’s needs. However, some plans needed further work to make them easier to understand and use. There was no clear evidence that families or those close to people had been involved in developing these plans. This meant that some important views and preferences may not have been fully captured.

These concerns were raised with the new manager during the inspection. They responded promptly and took immediate action to begin reviewing and improving the care plans. This included plans to make them more accessible and to involve families more actively in the care planning process.

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.

The service had systems in place to help protect people from the risk of abuse. Staff had completed safeguarding training and were generally confident in raising concerns when they identified potential risks. This helped to promote a culture of safety and accountability. People told us they felt safe living at the home. One person said, “I’m quite happy and safe.”

The service had processes in place to support people under the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). In one case, the new manager had identified that a DoLS authorisation may not have been necessary and took appropriate steps to review the situation. They also recognised that the person’s communication needs had not been fully supported during the assessment process. This showed a reflective and person-centred approach, with a commitment to ensuring people’s rights and experiences were respected.

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.

The service had systems in place to assess and manage risks to people’s health, safety, and wellbeing, but these were not always applied consistently or fully understood by staff.

Risks associated with the use of bed rails were not fully understood by all staff. This created a potential risk of harm due to inappropriate or unsafe use. In addition, care plans did not always contain clear or complete information about the risks people faced or the actions required to keep them safe. This meant staff may not have had access to the guidance needed to support people safely and consistently.

Environmental risks were not always well managed. Chemicals were found in unlocked cupboards under sinks in kitchen areas, and a large knife was stored in an accessible drawer. Several doors, including a cleaner’s cupboard and a bathroom undergoing maintenance, were left unlocked. These issues posed avoidable risks to people’s safety and wellbeing.

These concerns were raised with the new manager during the inspection. They responded promptly and began taking action to improve risk management practices across the service, including reviewing care plans, addressing environmental safety, and reinforcing staff training on safe practices.

People told us they were supported to manage risks, for example, they had the equipment needed to mobilise safely around the home. One person said, “I can get around on my own with my frame.” In addition, Personal Emergency Evacuation Plans (PEEPs) were in place, to support the emergency services if needed.

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 service had made efforts to create a comfortable and accessible environment for people using the service, but there were several areas where improvements were needed to ensure safety and suitability. Entry to the care home was not fully secure. Inspectors were buzzed in but remained in the building for approximately 15 minutes before any staff arrived to greet them. This raised concerns about the monitoring of visitors and the overall security of the premises.

It was positive that the dementia unit was located on the ground floor, allowing people easier access to outdoor areas. However, the environment itself was not fully dementia-friendly. Furniture and design features to support people living with dementia were not available, and the overall layout and décor did not reflect best practice guidelines for dementia care. The new manager was working with the provider’s dementia lead and new signage had been ordered.

All bedrooms were ensuite and equipped with automatic lighting, which supported safety and independence. There were also multiple seating areas throughout the home, offering people choice and comfort in where they spent their time.

While some aspects of the environment promoted wellbeing, the overall approach to creating a safe and supportive space for all individuals required improvement.

The provider made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective support, supervision and development.

The service had enough care staff on duty to meet people’s needs, and staff were safely recruited. There were gaps in staffing for activities, although recruitment was underway to address this.

Staff were aware of how to access and complete training. However, staff supervisions had not been consistently completed, which limited opportunities for reflective practice and professional development.

The service was not meeting the requirements of the Oliver McGowan Code of practice for training in learning disability and autism. This indicated a lack of understanding or oversight in applying the training requirements correctly. Additionally, some staff roles had not been appropriately considered in relation to training needs. For example, reception staff did not have food hygiene training, despite working behind the coffee bar. One chef was marked as not needing training in providing a positive dining experience, which meant they may have lacked knowledge of how to tailor food to support positive dining for people.

People told us they had confidence in the staff. Comments included, “I’m very happy with the staff, they can’t do enough for you,” and “The staff are good, they know what they’re doing, they look after me well.”

Overall, while staffing levels were sufficient, improvements were needed in training oversight, role-specific competencies, and supervision to ensure staff were fully equipped to support people safely and effectively.

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.

Staff had received training in infection prevention and control and understood the importance of keeping people safe from the risk of infection. However, there were several areas where practice and oversight required improvement.

People told us they were happy with the cleanliness of the home. One person told us, “It’s fantastic, clean, just like a hotel.” However, we found that some areas of the home were not cleaned effectively, and parts of the environment were not as clean or well maintained as needed. This suggested that systems to monitor cleanliness were not operating effectively and required review.

A person had been placed under isolation in accordance with infection prevention and control (IPC) protocols. Staff were following the correct procedures; however, a visiting family member propped the door open, which compromised the isolation measures and created a risk of cross-contamination to others. This highlighted the need for ongoing communication with relatives and visitors to ensure they understood and supported infection control practices.

Additionally, some dining tables were left with dirty tablecloths after lunch, which did not promote a consistently dignified or pleasant mealtime experience.

The new manager was responsive to these concerns and took immediate action to improve cleanliness and strengthen the oversight of cleaning practices within the home. This demonstrated a commitment to learning and improvement.

There were also some positive practices in place. The laundry area demonstrated a good dirty-to-clean flow, helping to reduce the risk of cross-contamination. The kitchen was clean and well maintained, with a food hygiene rating of 5 displayed.

Overall, while staff had received appropriate training and some areas of the service were well managed, improvements were needed to ensure infection prevention and control measures were consistently applied and monitored across the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The service had systems in place for the management of medicines, but these were not consistently effective, and improvements were needed to ensure safe and person-centred practice.

Staff had received training in medicines administration. Guidance was available to support staff in administering medicines prescribed to be taken as required, such as pain relief or anxiety medication. This helped ensure people received these medicines when needed, but only when appropriate.

Medicines in use were stored safely; however, medicines held in stock were not fully secured. away, which posed a potential risk. The provider was in the process of changing pharmacy services to improve reliability and support.

There were gaps in documentation and oversight. Administration information for one medicine was not fully recorded on the system. Some medicines require specific instructions around timing and method of administration to ensure they are safe and effective. Without complete information, there was a risk that the medicine could have been given incorrectly, which may have affected the person’s treatment or wellbeing One person’s care plan stated that their medicines should be crushed, but this was not happening in practice. Some medicines require specific instructions around timing and method of administration to ensure they are safe and effective. Without complete information, there was a risk that the medicine could have been given incorrectly, which may have affected the person’s treatment or wellbeing.

The new manager was responsive to these concerns and took immediate action to investigate and rectify the issues. This included reviewing care plans, updating medicine records, and strengthening oversight of medicines management processes.