Holme Lea

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

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. 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 the ways people’s medicines were managed safely.

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 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.

The service did not have a consistent approach to learning from incidents or feedback. While some audits were carried out, there was limited evidence of how findings were used to improve practice.

Opportunities to reduce risks following safety events were not always identified. For example, care plans and risk assessments were not always updated following safety incidents involving people whose behaviour could place themselves or others at risk.

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.

People’s care needs were assessed prior to them moving into the service and this helped to ensure their care needs were known and could be planned for. One relative told us “The home was very good. They drew up a care plan at the start, and it has been reviewed.”

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.

The service had a safeguarding policy in place, however records showed that incidents were not always reported to CQC and the local authority in a timely manner. However, the registered manager and area manager were responsive to feedback regarding this.

Relatives told us that generally they felt that people were safe. One person told us, “They do a good job in trying to keep (relative) safe.”

Where people were subject to restrictions, applications under deprivation of liberties safeguards (DoLS) had been made, however renewals had not always been made in a timely way. Where DoLS were subject to conditions, this information was not always reflected within the care plans. Capacity assessments and best interest decisions were in place, but they did not always clearly reflect the outcome of the decision, or that other key individuals in addition to the care home staff had been involved in the decision making process.

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.

Care plans did not always include enough details, for example, information about triggers for distressed behaviour or guidance for staff to follow to mitigate risks. Staff told us there was no guidance on how to manage people’s specific behaviour. Where people had specific conditions such as Parkinsons disease or Diabetes there was insufficient detail about the management of the condition or a separate care plan.

A new care planning system was in place and work was ongoing, including completing multifactorial falls risks assessments. However, these were not all in place at the time of our inspection.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home was clean, tidy and free from hazards. Some areas of the care environment were dated and in need of redecoration and a plan was in place for this. Some work had been completed, for example new carpets had been placed in some of the lounges. Feedback from relatives was positive about the environment. One relative told us “It is a good and calm place.” Further work was needed to ensure the home was dementia friendly and rooms personalised; action was being taken to complete this.

Health and safety checks were up to date and all recommendations from the latest electrical installation report had been completed.

Staff had access to emergency evacuation plans, which were all in order, to ensure events, such as a fire could be managed.

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.

We received mixed feedback about staffing levels; a relative told us “I notice that for long periods of time there are no carers around, I think there is a lack of staff.”

Staff told us that management did not ask them about staffing levels, and they sometimes felt rushed and did not get enough time to provide all aspects of care, with any spare time they had spent on completing records. We observed staff were not always readily available to support people. This was feedback to the provider.

Suitable recruitment processes were in place; however, interview records were not always fully completed.

Staff had completed a range of training, and most had completed a recent supervision. Staff told us that they were encouraged to develop in their role, however they felt they would benefit from specific training around managing behaviours.

There was no evidence within the training matrix around training specific for conditions such as Parkinsons disease and Diabetes. This was feedback to the provider.

Staff has had their competency assessments completed, but given the concerns identified in relation to medicines we were not assured this process was suitably robust.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean; bedrooms were free from clutter. Relatives told us that the home was always kept clean and fresh.

On the day of inspection not all staff were observed using protective equipment, we discussed this with the manager and area manager who advised that gloves are discouraged from being used and hand-washing is preferable, however aprons are still to be worn at all times. A consistent approach to this was shared with staff

The provider had an infection prevention control policy in place which guided staff on how to ensure safe practice was followed. There was a robust cleaning schedule for the kitchen and temperature checks for fridges and freezers were recorded.

The provider did not always ensure that medicines and treatments were safe or met people’s needs, capacities, and preferences. Staff did not consistently involve people in planning their care.

At the last inspection, we raised concerns about the management of certain medicines, including thickening powders, medicines with variable doses, and topical creams. At this inspection, we found some improvements: most people were no longer prescribed medicines with variable doses. However, further work was needed to improve the management of topical creams and the recording of thickener use. We found that not all prescribed creams were available for use, and records of topical cream application and fluid thickening were not always maintained.

We also identified multiple concerns about the management of time-specific medicines, such as paracetamol, which requires gaps between doses, and medicines like warfarin, where dosage advice is regularly reviewed. We raised a safeguarding alert regarding these issues, as people had been placed at risk of harm.