Hadleigh 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. This meant some aspects of the service were not always safe, and risks were not always mitigated. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulations in relation to safe care and treatment. Improvements were not found at this assessment and the provider remained in breach of this regulation. The provider was also in breach of the legal regulations relating to staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The Registered Manager reviewed incidents and accidents on a 1 to 1 basis, however, this process was not always effective.

Lessons were not always learnt to identify and embed good practice. For example, incidents and accidents were not analysed for themes and trends to minimise the risk of reoccurrence. We found the management team were open and transparent and wanted to drive improvements at the service.

The Registered Manager worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed or monitored. We saw people’s treatment escalation plans added to people’s care plans. The Registered Manager showed us where the original was kept and how these would be passed to relevant professionals when needed to ensure continuity of care and sharing of information.

The service 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 Registered Manager did not always share concerns quickly and appropriately. For example, we viewed a incident which showed people had come to harm from physical abuse, this incident had not been escalated to the local safeguarding team to ensure ongoing risks had been mitigated and managed to protect those individuals. We spoke to the Registered Manager about this incident, and they took action to inform the relevant authorities. This contributed to the continued breach of regulation in relation to safe care and treatment.

Staff understood their responsibility to keep people safe, 1 staff member told us, ”I flagged something up to them as there was a lady resident who was really quite loud, but I saw a member of staff shouting at her, this member of staff is no longer here, they took action. If I thought it had not been actioned, I would go to the owner, and I would go to CQC”. Relatives told us when concerns were raised or identified by the service, they involved the local safeguarding team, and appropriate action had been taken.

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. Where risks associated with skin breakdown were identified, they were not always doing all that was reasonably practicable to mitigate the risks. For example, air mattresses were not at the required setting, and where people had been identified as needing support with regular movement and change of position, between 2 to 4 hourly, records showed gaps of 7 to 12 hours.

This contributed to the continued breach of regulation in relation to safe care and treatment.

The provider did not always detect and control potential risks in the care environment, such as portable heaters, and appropriate risk assessments were not completed. Some people were not able to adjust the temperature within their bedrooms. During our first visit to the service, there was a person’s bedroom above 24 degrees. People using the service could have been at increased risk of the effects of heat such as heat exhaustion, heatstroke and other heat-related illnesses, including respiratory and heart problems. Environmental risks were not being regularly reviewed, for example, slips, trips and falls, administration and recording of medicines were recorded as needing to be reviewed in July 2024. We discussed this with the Registered Manager, who told us they would review these concerns and act. This contributed to the continued breach of regulation in relation to safe care and treatment.

The provider had measures to monitor fire safety and legionella risks. Staff told us there were weekly fire alarm tests.

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. Some staff told us they had regular supervision, records confirmed this. However, records showed, and the Registered Manager told us, staff had not received appraisals for several years. Some staff had not received specific training to support people living at the service, such as Dementia awareness. The provider did not have a systematic approach to determine sufficient numbers of staff to meet the needs of the people living at the service. Staff gave us mixed feedback about there being enough staff. A person living at the service told us, “A lot of time you have to wait for 30 minutes to be taken to the toilet, and sometimes an hour”.

Whilst we did not identify anyone who had come to harm, this contributed to the breaches of regulation in relation to staffing.

Staff were recruited safely. Relatives told us they knew staff and there was a stable staffing team. Comments included, “I would say they have very stable staffing; we know them, and they know us”, and “The staff have been the same main core for a while. They know (Person’s name), and he gets on really well with them”.

The provider did not always assess or manage the risk of infection. During our visit to the service, we identified some areas of concern regarding the cleanliness and lack of basic hygiene equipment, such as toilet roll. The service had recently received a complaint regarding the environment, but the action taken had not been embedded. For example, daily cleaning records. The Registered Manager told us they had been unable to find the cleaning records for the past 2 months. A staff member told us, “Sometimes it is not clean, and sometimes all you can smell is urine”. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe care and treatment.

At this assessment, we found improvements had been made regarding medicines. The service made sure medicines were stored, administered, and managed safely in accordance with prescriber instructions and best practice guidelines to ensure people who used the service were not placed at risk. The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Relatives told us, “The home sorts out all of that (medication) and we’ve never had any issues”, and another told us, “They always phone if there are any changes”.