The Haven

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 inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, infection control, medicines management, risk management, and environmental safety.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report all safety events. Lessons were not learnt to continually identify and embed good practice.

We found significant risk detailed throughout this assessment that the providers systems had not identified. We found gaps in oversight relating to medicines, environmental risks, ICP and manual handling.

In April 2025 an external company carried out a fire risk assessment and found a side escape route was being used for waste storage, with numerous combustible items left against the property. The risk assessment stated this was a significant fire risk, as well as a potential obstruction to a designated escape route. The fire risk assessment also stated, it is essential that this area is cleared immediately and maintained free from storage at all times. Escape routes must remain unobstructed and free from ignition sources. The provider had cleared the original waist but had not sustained the improvement. We found a significant amount of waste and hazardous items along the same escape route, putting staff, visitors and people at risk of avoidable harm. We asked the provider to clear the area as a matter of urgency.

While the provider acted during the inspection to address several urgent environmental concerns not all concerns were acted on. For example, we found 1 person’s denture pot was dirty with a build-up of grime. We reported this to the registered manager on day 1 of this assessment. When we returned on day 2, the denture pot remained in the same condition.

There had been a serious medication error made that resulted in 1 person being given too much medication and of the wrong dose. We reviewed measures put in place to prevent a recurrence of this incident and we found them to be insufficient. For example, prevention of the root cause of the error had not been included within the staff checklist. The checklist also stated, “Check the persons details on their wristband.” People at the service do not wear identification wristbands. This means lessons had not been learnt and people were at risk of being given the wrong medication.

We also found not all falls were investigated meaning there were missed opportunities for learning.
 

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

We found inconsistent information in people’s care plans, risk assessments and documentation used in the service to help staff know and understand people’s dietary requirements. For example, some people needed their diets modified to reduce the risk of choking. The level of modification was not always recorded correctly. This put people at increased risk of choking because staff did not have clear information to safely support them.

Care plans stated people’s mental health diagnosis’s however, information was lacking on how best to support the person during mental health crisis. For example, one person’s care plan states the person sometimes talks about ending their life and states there is sometime self-injurious behaviours. There was no risk assessment in place for suicidal thoughts or information detailing how staff should help a person de-escalate in times of crisis. The was no clear system for documenting incidents or analysis of incidents to look for themes and trends to help identify the triggers. Additionally, staff had not received mental health training. This put the person at increased risk of staff not knowing how to support them at a time of mental health crisis.

It is essential that documentation is kept up to date and relevant to people’s needs, especially where people may need to transition across different health services. We were not assured that correct information would be shared across different services when staff need to act quickly and share live documents.

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 registered manager told us they were in the process of embedding a new recording system to monitor safeguarding’s, however the system was not fully embedded due to technical issues.

The recording system for safeguarding’s, accident and incidents that was being replaced by the new system was not clear to follow. For example, entries were not always made in a chronological order making it harder to identify which entries related to which incidents and if all had been recorded.

Providers are required to complete statutory notifications for reportable incidents; this includes the death of people who use the service. We identified the death of 1 person that had not been reported to CQC. The registered manager said, “I was not aware I needed to complete a notification if the person died in hospital.” The registered manager told us they would back date notifications for others who had died in hospital where CQC had not been informed.

Not all falls had been investigated. Falls where people had been assisted to the floor by staff were not investigated. The registered manager said, “I would only investigate if the person had sustained an injury or if I felt more staff training was needed.”

Staff told us there knew how to recognise the signs of abuse and how to report these concerns.
One family member said, “There is a risk to people’s safety when they are left unsupervised.”

One staff member said, “Safeguarding’s are discussed and we learn how to prevent further incidents occurring and an action plan is put in place.” Another staff member said, “I would report the issue to the manager, if I felt it was not dealt with, I would contact social services and raise a safeguarding.”
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found significant risk to people, this included people who used wheelchairs being unsafely manoeuvred over a door threshold to access the garden. This posed a significant risk of them falling forwards out of the wheelchair and sustaining injuries. Additionally, the step posed a trip hazard for people using frames or a stick to mobilise, increasing the risk of injury. We asked the provider to take immediate action to reduce this risk and provide safer access to the garden.

Risk assessments lacked sufficient detail around risk mitigation. For example, whether lap-belts and foot plates were needed to minimise the risk of falling from a wheelchair and/or getting legs caught and injured by failing to use footplates.

Risk assessments for hazardous substances were not robust; we found denture tablets in 1 person’s room. We were told the person has a diagnosis of dementia. If a denture cleaning tablet is swallowed it can cause severe chemical burns, throat swelling and airway blockage putting people at risk of injury.

Additionally, we found a tub of thickening agent in an unlocked cupboard within the kitchenette and accessible to people. Given the service provides care for people with dementia and those who independently move within the service this placed them at potential risk of harm should they access and inappropriately use or ingest dangerous substances. Fluid thickening agents are frequently prescribed for swallowing difficulties (dysphagia) but can cause a fatal airway obstruction if the dry powder is ingested, and potential lung injury if aspirated.

You can read more about the risks to people in the ‘safe environments’ section of this report.

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

We found significant and widespread risk to people at The Haven. The provider had failed to work within their own Health and Safety Policy and Procedure. Not all areas of the service had been subject to a comprehensive and accurate risk assessment that reflected the nature of the service being provided. With the exception of the central enclosed garden, all other garden areas, which the registered manager confirmed were accessible to both people and staff, were found to be poorly maintained, containing accumulations of waste and unused furniture. In addition, the maintenance shed was left unlocked, allowing unrestricted access to tools, including power tools and gardening equipment.

The providers Health and Safety Policy stated the responsible person for the care home must ensure that emergency routes and exits lead as directly as possible to a place of safety, remain unobstructed at all times, and can be safely and swiftly used by vulnerable people. This includes keeping external fire routes free from combustible waste. We found a large amount of combustible waste along 1 of the fire routes. We also identified a gate along the same fire exit route had a padlock securing it locked. This meant people would not be able to swifty exit and would be at increased risk of injury.

We asked the provider to make immediate improvements to the external area and reduce the risk to people. The provider took action and cleared the area, removed the lock from the gate and added new signage.

The provider made sure there were enough qualified, skilled and experienced staff. The provider had a safe recruitment process in place. However, staff did not always work together well to provide safe care that met people’s individual needs.

A stakeholder said,” On the whole the care seems ok, the senior management and carers are very good and engaging with the residents. The junior carers appear to require a lot of prompting and lack initiative, but I haven’t seen them not do anything when asked to. Carers are always polite and cheerful with the residents.”

We received mixed feedback from staff that included, “Overall, I believe The Haven is committed to providing safe, person-centred care. Staff work hard to meet the needs of the people they support and are encouraged to continuously improve the quality of care. I appreciate being part of a team that strives to promote dignity, respect, and independence for the people who live at The Haven.”

Another staff member said, “Some staff members have got nothing better to do than bring the home down. I feel if some staff got on with their job and concentrated on creating a lovely place to work, things would be great.”
A family member also described an atmosphere between staff and said sometimes staff are describing their dissatisfaction in front of people sitting in the lounge.

The registered manager spoke openly about some of the challenges faced within the team dynamics and discussed how these are being managed through HR processes.

The provider had a safe recruitment process in place.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control leads had not been given additional training to ensure they had an in-depth knowledge of ICP and audits did not pick up the concerns we found.

We found infection prevention and control (IPC) measures were poor, which placed people at risk of acquiring infections. For example, toilet brush holders in en-suites and communal toilets

were noted to contain dirty liquid, and brushes were not clean, creating a breeding ground for bacteria and other microorganisms, potentially leading to increased risk of infection.

We found dirty denture pots, dirty light pull cords, grime build up in some bathrooms and rust in 1 plug and chain.

One person’s mattress surface cover had started to crack and breakdown. Mattresses and covers in poor condition are known to be a source of healthcare associated infection. Although the mattress was replaced immediately, staff told us, there was no set audit carried out to routinely assess and identify mattresses, and mattress covers in poor condition.

Another person’s bed had been made but the sheets were dirty and the bed had crumbs on it.

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

Medicine administration records (MARs) were not reflective of people’s prescriptions or in accordance with prescriber instructions. For example, where medicines had been stopped by a GP this had not been recorded on MAR charts. In some cases, MAR charts did not have the stopped medicine marked a stopped and signature boxes were blank with no explanation of whether medication had been administered and not signed for, not given, or refused. Other MAR charts where medicines had been stopped had a small line through the middle week on the MAR with no explanation what this means. This put people at increased risk of medicines being administered after a GP had stopped them.

We found poor documentation for pain patches. Records did not accurately identify where patches had been applied or removed from. Rotation of patches is essential to stop skin damage, keep the medicine working right, and let old spots heal. Putting a new patch on the exact same spot blocks skin from breathing and can cause skin rashes.

Systems to store medication safely were not robust, during this assessment a staff member brought to the office a box of 12 tablets and said they had been found in an empty bedroom. We identified these tablets had been temporally stopped by a GP 14 days earlier. These tablets had not been booked out for returning to the pharmacy and not been carried forward to the stock on the new MAR chart. The tablets had not been identified as missing. This highlighted a failing in the providers processes to safely monitor, store and audit medicines.

Staff were not working within the provider’s medicines policy and medicines marked for returns were not being stored safely. Additionally, the registered manager had not identified the concerns identified in this report.