Hollyfields

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 66 (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. Processes were in place to enable lessons were learnt and shared with staff to identify, improve and embed good practice.

Staff completed a report when an accident or incident occurred, this was reviewed by the registered manager to ensure any actions needed to mitigate any risks had been taken. We reviewed accident and incident records and found that several people had sustained injuries during moving and handling. The registered manager identified a pattern and arranged additional training for all staff to reduce the risk of further incidents. This demonstrated the provider had a proactive approach of learning and responding to incidents and events.

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.

Leaders completed pre-admission documentation prior to people moving into the service to gather information about their needs and this was shared with the team prior to admission. Staff monitored people’s health conditions and ensured timely referrals were made to other services. For example, when 1 person’s fluid intake was below their target, staff liaised with GP to identify what actions were needed to avoid the person becoming dehydrated and unwell. Records relating to people’s care needs were stored on an electronic care system which allowed information to be easily shared, for example, when people were attending hospital. A health professional working with the service told us staff escalated concerns and made referrals to the appropriate partners when required and in a timely manner.

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 told us they felt safe. Comments included, “I feel safe, I have not had any falls or accidents since I came here” and “I feel safe, the staff are here to help, and the door is locked”. Staff had undertaken training in safeguarding. They understood the types of abuse and how to raise concerns internally and to external agencies. The registered manager investigated safeguarding concerns and acted in accordance with the duty of candour by being open, honest and providing information to people and their representatives.

The provider did not always work well with people to understand and manage risks.They did not consistently provide safe care that met people’s needs. We observed some people drinking from plastic cups with spouts, but not all had recommendations from a speech and language therapist to use these. This increased the risk of aspiration. Aspiration occurs when something enters the airway or lungs by accident and can lead to health problems such as pneumonia. The registered manager stated that two people had capacity and requested this type of cup; however, their care records did not reflect this.
Staff assessed risks to people’s health, safety, and welfare, including falls, skin damage, weight loss, and choking. They completed risk assessments and reviewed them regularly. Most risk assessments were detailed and thorough, but we identified some that lacked detail or were incomplete. For example, 1 persons care records did not give details of the signs and symptoms related to their health condition to enable staff to respond accordingly. Daily records indicated that staff generally managed risks in line with assessments. For example, where people required regular repositioning to prevent sore skin, staff carried this out as detailed in their assessment. Staff made sure any required equipment was in place.
People felt their individual risks were managed well. One person told us, “I have a call bell here, I have had several falls, so now I press the bell, and someone will come and walk with me”.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
At the time of our assessment, extensive refurbishment work was underway. The provider had completed a risk assessment to manage associated hazards. The maintenance team carried out regular checks and audits to ensure the environment remained secure. Staff ensured people had the equipment they needed, and this was routinely checked to ensure it was functioning correctly. Each person had a personal emergency evacuation plan to guide staff in the event of a fire. Staff completed health and safety and fire safety training, participated in fire drills, and told us they felt confident responding if the fire alarm was activated.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. We found there were occasions where people required assistance and there were no staff available to support them. Some staff felt they did not always have enough time to spend with people other than completing care tasks. Despite our findings, people and their relatives did not raise any concerns regarding staffing levels. However, we shared our observations with the registered manager who informed us approval had been given for an extra member of staff in the morning. People felt staff were well trained. One person told us, “There are always 2 staff to support me when transferring, they know how to use the equipment, I feel totally safe”. The provider had systems in place to ensure safe recruitment practices were followed. Relevant and appropriate recruitment checks, such as the Disclosure and Barring Service (DBS) were in place. The DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions

The provider assessed and managed the risk of infection and had an up to date policy. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People told us the environment was kept clean. One person told us, “My room is cleaned every day, I like everything neat and tidy” another person said, “The staff always use gloves and aprons when they support me to get up in the mornings, I understand it is to stop the spread of germs”.
We identified a couple of shortfalls, including empty hand sanitisers and broken foot-operated bins, and fed this back to the provider. They assured us these issues would be addressed promptly.
 

The provider did not always make sure that medicines and treatments were safe.Medicines were mostly managed and administered safely. However, we found some improvements were needed. Cabinets in people’s bathrooms containing medicinal creams and other items that may cause harm were not secure. We found most of them were locked however, the key was accessible to which meant people could access the contents. We fed this back to the provider. Shortly after our site visit, we received confirmation action had been taken to address this safety concern. Other areas of medicines were well managed. Staff stored medicines safely. They completed daily checks of fridge and room temperatures to ensure medicines were stored at safe temperatures. Guidance was in place for ‘as required’ medicines so staff knew when these medicines should be given. People told us, “The staff give me my medication; I have never had any problems or run out of stock’ another person said “The staff give me my tablets. I have never experienced any problems or missed any doses”.