Haven Nursing Home

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.

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. Opportunities to learn lessons and embed good practice were not always identified.

Accident and incident forms were completed by staff and reviewed by the registered manager each month. However, analysis of accidents and incidents had not identified people’s risk assessments and care plans were not consistently reviewed and updated in accordance with the provider’s policy and procedures. For example, we identified 2 people who had sustained falls 3 weeks prior to our inspection. Their falls risk assessments had not been reviewed to ensure any increasing risks were identified and planned for.

Whilst monthly reviews ensured people had been referred to external healthcare professionals where required, they did not identify any trends or patterns at service level. For example, the time-of-day accidents/incidents occurred or the location within the home. This meant potential opportunities for learning were missed. The registered manager immediately addressed this following our feedback.

Following incidents, lessons were shared with staff through handovers between shifts and team meetings. One staff member told us, “If there was a fall, witnessed or unwitnessed, first you tell the nurse. Then you fill in the document on the (electronic system). The nurses also do a form and tell you if you need to check the resident more often. If you’re not on shift, you would be told at handover.” Another staff member told us, “We talk about the residents in our meetings. If we have a problem or worry, we talk about how we might do things differently, better.”

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 worked with other health and social care professionals to ensure people’s needs were met. One external healthcare professional told us, “The nursing staff are extremely well trained. They recognise deterioration or changes early on and raise concerns accordingly.”

People who needed to be transferred to hospital owing to health care emergencies did so where needed. Processes were in place to ensure information was shared with paramedics and hospital staff. This included information about any risks to people’s health, their medication and their wishes for future care. Care plans were updated to reflect any changes in people’s support following their discharge from hospital.

There were systems to ensure appointments with external healthcare professionals were not missed. Relatives or a staff member supported people to healthcare appointments to ensure information was shared and any advice for future treatment recorded and known.

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. There was no effective system to ensure legislative requirements were always followed to safeguard people when they had restrictions in their care plans.

The Mental Capacity Act 2005 allows some restrictions to be used, but only if they are in a person’s best interests and necessary and proportionate. Where people’s human rights were restricted and detailed within their care plan, applications to deprive people of their liberty (DoLS) had been submitted. However, there was no effective system to ensure approved DoLS were reapplied for prior to their expiry date. This meant people had restrictions in their care which had not been reviewed to ensure they remained appropriate and in their best interests.

Two people had conditions on their approved DoLS which required referral to other healthcare professionals and on-going monitoring. Whilst we were assured the referrals had been made, care plans had not been implemented to ensure the ongoing monitoring was known and actioned by all staff. If the conditions of a DoLS authorisation are not met, the deprivation of liberty may no longer be in the person’s best interests and could infringe their human rights. The registered manager acted immediately to implement a system to monitor DoLS applications, approvals and any conditions imposed.

Records demonstrated accidents and incidents had been reviewed to identify potential safeguarding concerns which had been referred to the local authority. However, we identified 2 incidents which potentially met the safeguarding threshold. Although the registered manager assured us they had considered if safeguarding referrals were required, their rationale for not making the referrals was not recorded. This meant opportunities to ensure people were consistently safeguarded in relation to their responses to specific situations were not always taken.

People told us they felt safe and secure at Haven Nursing Home. One person told us, “I’m safe and it’s mainly because someone’s always around.” Another person said, “I’m very safe; it is the staff who keep me safe.” One person told us they sometimes got anxious when people entered their room uninvited, but staff responded quickly when they called for assistance.

Staff understood their responsibilities in relation to safeguarding and were confident if they reported concerns, these would be taken seriously. One staff member told us, “We covered that (safeguarding) in our training. Thankfully I have never witnessed any abuse. Be sure if I did, I would act straight away by telling our manager. I have never had to do that but [deputy manager] would be on it straightaway and would tell you (CQC).” Another staff member told us they would be concerned by, “Bruising or if a person had suddenly gone quiet and changed their behaviour or become isolated and didn’t want to be washed by a staff member." They went on to say, “I would go to someone higher first and if it did not get escalated, then I would go through whistleblowing."

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People felt confident staff supported them in a way that reduced risks associated with their care. One person told us, “They manage my risks very well indeed.” A relative commented, “[Name] is hoisted. They don’t hurt her; she would tell me.” Another relative told us staff responded appropriately when their family member demonstrated anxiety or distress.

Care plans informed staff about risks to people’s health and wellbeing. This included risks of skin damage, mobility, eating and drinking and specific medical conditions. Risk assessments promoted and supported positive risk taking. For example, 1 person had expressed a wish to continue smoking. A care plan had been developed with the person to mitigate the associated risks. One staff member told us, “If anyone had a fall, the nurses ring the family to let them know. When the family come in, they chat to the nurses about it.”

Staff understood their role in the management of risks. One staff member told us, “We are responsible for their (residents) safety. You are always on the lookout for anything that’s been left lying around, a trailing wire or it could be someone’s shoe has come off which another resident could trip over. If you see something and you can sort it, you do; if you can’t, you tell the maintenance man or the nurse.” Another staff member commented, “The nurses do the assessments (risk), but they do ask us because we are the one’s working with the residents every day.”

Staff had completed safer people handling training. People were assisted to transfer safely and fully informed during the process. For example, 2 staff assisted a person to transfer out of a lounge chair using a hoist. Staff spoke to the person and explained what they were going to do and continued to offer reassurance throughout each stage of the transfer.

The provider did not always detect and control potential risks in the care environment.

Fire safety was not consistently well managed. Some of the provider’s fire safety management policies and procedures were not accurate and some staff did not have a good understanding of their responsibilities and the actions they needed to take to keep people safe in the event of a fire.

We identified some issues in the environment which impacted on fire safety. For example, a hole in a corridor ceiling due to a water leak in March 2025 created a significant risk as a fire could quickly spread along the void in the open roof space. In the kitchen there was a stairgate across a fire exit which had not been risk assessed. The emergency ‘grab bag’ did not contain sufficient essential items to support staff in case of an evacuation of the service. The registered manager responded immediately to address the fire safety issues identified.

The provider had processes to ensure equipment was regularly checked and maintained in good order.

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.

People and relatives were positive about staffing levels in the home and generally felt staff were available when they needed them. Comments included: “There’s loads of staff”, “Plenty of staff as a whole” and “They are very busy all the time; it can be very difficult in the afternoon to get staff.”

The registered manager regularly reviewed people’s needs to identify required staffing levels. This ensured there were enough skilled and experienced staff to keep people safe and deliver the care outlined in their care plans. Where a need was identified, for example to support people to external healthcare appointments, additional staff were deployed. During our inspection we saw staff were available and responded to people when they needed support.

Staff told us there were enough of them to meet people's needs because they worked as a team and communicated well together. One staff member told us, “In all the years I have worked here there was only 1 occasion when we were short staffed because someone went off sick and management couldn’t get cover. It was only for an hour and a half.” Another staff member commented, “We always have enough staff. It is probably the most staff in all the places I have worked. I really like it because you have more time to spend with the residents.”

There were processes in place for staff induction and training to ensure staff were competent to provide safe care. The provider’s recruitment processes ensured the suitability of staff before they started working in the home.

The provider did not always assess or manage the risk of infection. They did not always control the risk of it spreading.

Staff had completed infection, prevention and control training. One staff member told us, “We’ve got gloves and aprons and masks. We have a plentiful supply. We also have hand gel. I did the training when I started. It explains why it’s good to wear gloves and aprons and masks. It’s about protecting the residents and the staff.” However, our observations demonstrated some staff did not always work in line with the provider’s policy and procedure.

Those areas of the home that had been refurbished were clean and well maintained. Other areas needed cleaning and maintenance. For example, numerous door frames had chipped paint and splintered wood which meant they were difficult to clean. Audits completed by the management team were not always effective as they did not include checking all aspects of infection prevention and control. This meant areas requiring improvement were not consistently identified and addressed.

The laundry was well organised, and the clinic room was very clean. Waste was disposed of in line with good practice guidelines.

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.

Medicines were received, stored, administered and disposed of safely. Where people were prescribed medicines to be given 'as and when required' there was information to inform staff when these should be given.

Staff received training in safe medicines management and the provider's medicines procedures and felt confident following these. Our observations confirmed staff worked in accordance with good practice guidelines when handling and administering people’s medicines.