Heathgrove Lodge Care 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 good. At this assessment the rating has remained 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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed safe practice.

There was a learning culture amongst the staff, manager and the provider. Incidents and accidents were well managed. Incident reports showed the actions taken to respond to occasions when people fell, had an injury, and when people’s mental health needs deteriorated. Their needs were reviewed, monitored by staff, and referrals were made for health input. When we fed back issues which we had identified with IPC practices and people being at risk of not having their cultural needs met, both the manager and provider took action to rectify these issues. They showed us what they had done and talked us through what they intend to do.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care.

People received timely intervention from health professionals when they were unwell. Staff maintained good records to show people’s medical needs were responded to quickly and were reviewed after the initial health input. Health professionals we spoke with told us staff and the manager gave detailed accurate information to them about people’s health needs. Senior staff had got to know the regular health professionals who supported people in the home. These professionals told us they felt confident people were safe.

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. The provider shared concerns quickly and appropriately.

Staff were clear about their responsibilities to share concerns with their supervisor, manager, provider, or CQC if they needed to. Staff were mindful to the potential risk of people experiencing abuse. Which should help them to pick up on any potential indicators of a person experiencing harm. The manager also knew they must report concerns to the local authority if needed.

The provider did not always work well with people to understand and manage risks. Staff did provide care to meet people’s needs that was safe.

People had risk assessments in place, but 1 potential risk for a person had not been assessed with them to understand the potential associated risks. Another person had a risk assessment in place regarding a personal lifestyle choice; however, this was not holistically and thoroughly assessed. We spoke with the manager about this, and they revised the assessment and their care plan twice following our feedback. The provider and manager audits should have identified these shortfalls and sought best practice advice. No one came to harm as a result of this, but it was a shortfall in how they involved people and considered the risk.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Equipment used was tested yearly by external companies to ensure it is safe to use. The building had a current annual fire safety assessment and various fire related equipment was checked routinely. Any issues were identified and actioned quickly.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together to provide safe care that met people’s individual needs.

There was enough staff to meet people’s needs in relation to daily tasks and most social needs. One person said, “The staff are very good at coming quickly if I press my bell.” Staff said they felt there was enough staff and they were asked by the manager about their views on staffing.

Staff received training in relevant areas to their work. Staff were safely recruited. Staff received regular supervisions and attended team meetings. Staff told us they felt supported by the manager and supervisors. One member of staff said, “I like a manager who cares about the staff as much as the people who live here, and [name of manager] does.”

The provider did not always manage the potential risk of infection. They did not always detect the potential risk.

The home looked and smelt clean. We saw the cleaning staff working hard cleaning people’s rooms thoroughly. Staff also adhered to safe IPC (infection protection control) practices. However, there were shortfalls with IPC. For example, some people had historic stains on their bedding and some of the lounge chairs upholstering had peeled which posed an IPC risk. We spoke with the manager who directed the laundry staff to dispose of all the stained sheets and asked them to dispose of any new stained sheets in the future. New furniture was ordered. However, the provider and manager’s audits did not identify these issues and resolve them without our prompting. The provider made corrections to their auditing processes.

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.

People received their medicines as prescribed. There were no errors identified in the medicines check we completed. People who had ‘as required’ medicines had clear protocols for staff to follow and guidance if something went wrong including if a person had a negative reaction to a medicine. There was one case however, when staff were administering a person’s ‘as required medicine,’ daily for over a month. When we raised this issue, we were given some further context. However, managers and senior staff who administered this medicine should have raised how often this medicine was being given and evidenced what the GP then advised. The manager acknowledged this shortfall in best practice.