Turning Point - Hollygrove

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 good practice.

Incidents and accidents were recorded and reviewed by management and the provider. Follow up actions were taken where needed to make sure all incidents were managed appropriately. The registered manager told us there were various opportunities for staff to discuss learning from incidents. They said, “We make sure we learn as a team, we do de-briefs, we raise in team meetings, supervisions and staff feel able to raise any concerns.” Staff confirmed they discussed and reflected on incidents and any learning. One member of staff said, “Whoever is involved sits down and talk it through. We can get more help if needed and ask for more training too.”

The provider carried out thematic reviews of incidents. This meant registered managers were supported to review incidents looking for themes and trends. Discussions were held with regional managers and peers to reflect and discuss learning from all of the provider’s services. This helped identify different ways to prevent recurrence and apply learning from others across all services.

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.

The provider had systems to make sure people safely transitioned between services. For example, with admissions to hospital, a copy of people’s medicines records and a hospital passport were sent with them. This enabled hospital staff to know what people’s needs were and how to communicate with people. It also shared important medical information and details of people’s health conditions.

When people were being discharged from hospital, staff made sure everything was in place to support people safely. If new equipment was needed this was sourced and staff had been provided with training on using it. Staff regularly spent time with people in hospital, observing and learning from healthcare professionals what support people needed. The registered manager told us they were proud of the collaborative working they had done with hospital staff during a recent discharge. They said, “2 staff from the hospital came here and worked with the team on moving and handling. They spent 3 hours here engaging with staff and others.”

Relatives told us they had no concerns about how people moved between services and appreciated how people could visit the service for short periods of time before moving in. One relative said, “It was an excellent transition for [person], they would go on day visits. Each visit [person] wanted to go there more and more.”

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 and appropriately.

People and relatives said people were safe at the service. Comments included, “[Person] is definitely safe there, we have never had any issues” and “I feel [person] is in a safe environment and their human rights are respected.”

Staff received training on safeguarding and understood their responsibilities. Staff told us the different types of abuse and what they would do if they were concerned. Staff understood the importance of recording information and reporting all concerns. One member of staff said, “There is an open-door policy, so we can reach out to the manager if we are unsure of the process.” The registered manager told us staff were aware of how to report any concerns and to which organisations. Safeguarding incidents had been shared with the local authority safeguarding teams.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service was working within the principles of the MCA and had applied for DoLS authorisations appropriately. For those that had been authorised there were no conditions.

The provider did not always work well with people to understand and manage risks. Risks to people’s safety had not always been assessed when needs had changed. This meant the risk management plans were not always updated. We also found conflicting information within people’s records around management of some risks. For example, for people needing thickening agent added to fluids there was conflicting information on how much thickener to add to fluids. Whilst we did not see any harm, risk management plans need clear and accurate guidance, so staff know how to provide safe support. This was raised with the registered manager during our assessment who took responsive action to update people’s records.

Leaders had completed work on developing staff knowledge and understanding on restrictive practice. People had restrictive practice care plans which recorded all lawful restrictions in place and what support staff had to provide. If people experienced distress or needed support with specific behaviours, this was recorded in positive behaviour support plans (PBS). Staff were provided with specialist training on PBS, and the provider had a specialist team who were able to provide advice and additional support.

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

Health and safety checks for the environment and equipment were regularly completed. This included for areas such as fire systems, water monitoring and equipment safety. The provider had internal checks which were regularly completed and checks for external contractors.

Leaders completed regular health and safety audits which helped identify any shortfalls. Any actions were added to a service improvement plan and monitored until completed.

During our site visit we observed staff using equipment safely. People and relatives did not share any concerns about health and safety.

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.

Staff had been recruited safely and when they started work, they were allocated an ‘induction buddy’. This was a more experienced member of staff who was available to support and signpost to resources. The provider had an induction process which included training, probationary meetings and a period of shadowing other staff. The registered manager said they did not allow new starters to carry out any personal care until staff had got to know people. Staff were able to complete work-based qualifications and leaders had completed management level qualifications.

We observed there were sufficient numbers of staff to support people safely and the service did not use any agency staff. However, some staff said there were not enough staff. Comments included, “They have been recruiting but need to recruit more” and “There are not enough staff. Individual needs have changed so much.” We shared this feedback with the provider and registered manager.

People and relatives said they thought there was enough staff and staff were well trained. One relative said, “There is enough staff and they have the correct training.”

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.

Staff were provided with training on infection prevention and control (IPC) which was regularly refreshed. There was personal protective equipment available for staff to use. We observed staff followed safe IPC guidelines.

The service was clean and staff supported people to be involved in keeping all areas clean and fresh.

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

Staff competence to administer medicines had not always been assessed. Staff had been provided with medicines training, but competence checks did not cover all the ways staff were administering medicines. We found no harm to people, however, a competence check for administering medicines via all routes was required. We shared this feedback with the provider who told us they were reviewing their medicines policy and guidance.

We found some topical creams had not been dated when opened. This meant the provider would not know when creams reached their expiry date. Staff took immediate action to address this shortfall.

People had support from staff to manage their medicines. One relative said, “I have no concerns about the support [person] gets in taking medications.”

People had an individual medicines administration record (MAR) which staff used to sign when people’s medicines were administered. We observed there were no gaps in recording. If people had ‘as required’ medicines, there was guidance available for staff to know how much medicine to give and when.