Hallaton Manor Limited

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 good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 identified and acted on safety incidents. Staff listened to concerns about safety and investigated and reported safety events. Prior to our inspection, we received concerns around safety incidents relating to people’s care and treatment. We reviewed records of incidents and saw lessons had been learnt and measures implemented to reduce the risk of re-occurrence. The registered manager analysed incidents, accidents, near misses and outcomes each month to ensure actions were taken to reduce risks. Where the provider was unable to reduce the risk to an acceptable level, they had liaised with other agencies to identify safer support for people. Staff understood their responsibility to report and record any concerns and told us they were confident the management team would listen and respond appropriately. They told us, “[Registered manager] encourages us to discuss things and raise concerns. They always listen and act on any concerns” and “[Registered manager] called all staff together after a potential safeguarding incident. They reported it (to other agencies) and then went through processes with us to help our learning.”

The provider had systems in place to work with people and healthcare partners to establish safe systems of care. These had not always proved effective in managing or monitoring people’s safety. The registered manager completed assessments prior to admission to identify if the service was able to meet people's needs safely. This information was shared with staff prior to a person’s admission to the service. The registered manager had identified a more robust assessment process was required to ensure all relevant information was captured and reviewed prior to any admission. This would help to ensure information was detailed and accurate to support a smooth transition to the service. Staff worked with health care providers to ensure safe systems of care. However, a difference in expectations had resulted in inconsistent communication and support between some healthcare partners and the service. The registered manager had escalated concerns and was working with agencies to ensure safer systems of care.

The provider worked with people 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 and co-operated with other agencies to help people to keep as safe as possible. People were encouraged to understand how to keep safe and how to raise concerns. A person told us, “It just feels secure here; I feel safe. I don’t ever want to move.” Staff had undertaken safeguarding adults training and understood their role and responsibilities in relation to safeguarding. A staff member told us, “People are safe here. I have never witnessed any abuse or neglect or bad care. I know how to escalate this if needed.” Staff had access to relevant guidance about safeguarding. The registered manager audited staff’s understanding of safeguarding as well as seeking the views of people and relatives. The registered manager maintained up to date and accurate records relating to people’s DoLS (Deprivation of Liberty Safeguards). This helped to mitigate the risk of people being unlawfully restricted.

The provider worked with people to ensure potential risks to people’s care were understood and managed. Staff assessed a range of potential risks to people and understood how to manage them. One person described how staff supported them when they had a health crisis as they understood and responded to the early symptoms which helped to mitigate risks. Information within people’s care plans and risk assessments guided staff on how to support a person to keep them safe, as far as possible, by mitigating known risks. Staff told us they worked alongside the management team to ensure care plans and risk assessments were current and reflective of the person’s needs. Some people using the service had complex emotional and mental health needs. Incidents had occurred where people had incurred harm through poor choices around risk taking. For example, a person was at known risk of leaving the service unsupervised. Staff had tried measures to mitigate this risk through best interest processes, but these had proved unsuccessful. The registered manager was in the process of working with placement commissioners to restore 1-1 hours for the person, but risks remained in the meantime. Additionally, a person was at high risk due to them declining engagement and rejecting treatment from healthcare professionals. A lack of cohesive working between healthcare professionals and the service had contributed to the person being at risk. Although robust records were in place to audit actions, responses to incidents of risk were not always escalated in a timely manner to the right people. The provider and staff had taken learning from this to clarify roles and responsibilities around complex risk mitigation with partner agencies. Staff used safe approaches and techniques to support people to mobilise around the service. However, we observed one occasion where staff approaches were not in line with best practice. We raised this with the registered manager who addressed this following our inspection visit.

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 provider had made improvements to the décor which meant the premises appeared brighter, clean and well maintained overall. Utility and equipment checks and audits were completed to reduce the risk of an unsafe environment. There was a responsive maintenance service in place to ensure compliance and timely repairs were carried out. People had up to date Personal Emergency Evacuation Plans (PEEPs) in place, to guide staff on how they needed to be supported in the event of an emergency such as a need to evacuate the building. The provider and registered manager was constantly evaluating the premises to ensure it was safe and suitable to meet a variety of people’s needs, including people living with dementia.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The registered manager used a tool to calculate and review people’s staffing needs. We saw there were enough staff in each area of the home to keep people safe and to attend to their needs. Some people required 1-1 staff support to mitigate known risks. We saw this was in place during our inspection visit. A staff member told us, “There is always enough staff here. If we are allocated 1-1 with a person, we don’t get called away to help other people. We stay with that person.” People told us they felt there were enough staff. Comments included, “I’ve got a buzzer (call button) in my room to ask for help. If I use it, staff are right on the button and come straight away” and “There are enough staff. It’s busy but they don’t rush me.” The provider had robust and safe recruitment practices which ensured staff were recruited safely. Once recruited staff received an induction to their role, training and supervisions. A staff member told us, “I had good induction and the training is repeated, mostly annually. The training person comes when needed and it’s always done on time.” Training records showed staff undertook a range of training to meet essential and specific needs of people, including mental health.

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. We found environments to be clean and Personal Protective Equipment (PPE) was supplied for staff to use when required. We saw staff used this appropriately, for example during mealtimes and whilst administering people’s medicines. Our observations showed that the service looked visibly clean.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff received training in administering people’s medicines and this included how to safely administer specialist medicine, for example, in the case of a seizure. Staff competence was regularly assessed, and they worked closely with other healthcare professionals to ensure people’s medicines were regularly reviewed. For example, staff had been trained and assessed by healthcare professionals to administer insulin for people where this was required. People had robust medicine plans in place which supported safe administration and monitoring. Detailed, person-centred guidance was in place for 'when required' (PRN) medicines, including pain relief and medicines to support people when they became distressed. These included clear instructions on when and how to administer the medicines based on individual needs and behaviours. Staff gave examples of techniques they used to help minimise distress without resorting to medication. Audits and checks were carried out to make sure people’s medicines were being administered safely. Processes were in place to ensure any medicine errors were documented, reported, investigated and any required action taken.