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 there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. At this assessment and the provider remained in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to staffing. Improvements were found at this assessment, and they were no longer in breach of this regulation.

This service scored 56 (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. Lessons were not always learnt to continually identify and embed good practice.

Routine analysis of accidents and incidents had not been completed to identify areas of learning or opportunities to mitigate future risk. The provider had recently implemented new systems to improve analysis, and work was ongoing to embed this.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Since our last assessment, there had been no new admissions to the service whilst the provider focused on making improvements. At the time of this assessment, 2 people had been given notice to leave the service because their needs could no longer be met. The provider gave assurance that people admitted to the service in future would have full assessments before placements were agreed to ensure their needs could be safely met.

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, appropriately and investigated incidents.

All incidents relating to people’s safety had been reported to both the local authority and CQC. The provider worked openly with professionals to share concerns, learn from incidents and embed good practice.

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.

People had risk assessments in place; however, these were not always correctly completed. For example, one person’s risk assessment said there had been no previous incidents of choking, however, records showed they had experienced a serious choking incident. At our last inspection we found people’s repositioning records were poorly completed, at this inspection we saw there were still unacceptably large recording omissions in one person’s records. This meant it was unclear if care had been delivered in line with the persons assessed needs. Poor oversight of people’s risks exposed people to risk of harm and contributed to the continued breach of regulation 12.

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 provider had made some improvements to the environment and work was ongoing to ensure all risks were identified. During this assessment process, the provider engaged an external company to complete a full environmental risk assessment. In house maintenance had a schedule of works and had identified some immediate improvements needed, such as changes to a fire exit and windows that needed repairing.

One person’s relative told us they had noticed improvements. They said, “It doesn’t seem to be so noisy, it’s calmer. I am very happy with the care, and I think [relative] is 100% safe.”

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.

Shortly before this assessment, the provider identified that staff administering medicines had not received appropriate training or been assessed as competent to administer medicines. The provider worked with the local authority to quickly rectify this, however, this had exposed people to risk of harm.

Not all staff had received supervision or appraisal, and work was ongoing to address this.

Systems were in place to ensure staff were safely recruited, however, references had not always been sought in line with the providers policy.

Following changes in management, there had been significant changes to the staffing team and new staff were being supported to complete the required training. One staff member said, “Training is definitely getting better, we have had a lot of practical training recently.”

There were enough staff to meet people’s needs; the provider had introduced a dependency tool to ensure staffing levels were appropriate. One person’s relative told us, “There are always plenty of staff when I visit, no one is waiting, and they don’t take long to answer the door.”

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.

At our last assessment we identified areas of concern regarding the cleanliness and lack of basic hygiene equipment. At this assessment, improvements had been made. The environment was clean and odour free. Staff had access to appropriate personal protective equipment and cleaning schedules had been implemented.

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

Shortly before our inspection, the provider identified multiple stock and administration errors within the medication administration system; there was no evidence people had been harmed. Staff had completed refresher training, and the local authority provided support to ensure people received their medicines safely whilst improvements were made. Whilst we found that improvements had been made, people did not always receive time specific medicines at the appropriate times and prescribing directions such as ‘with or after food’ were not always adhered to. Systems to monitor the safe administration of medicines were being developed and needed embedding. This contributed to the breach of regulation 12.