Tandridge Heights

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

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 changed to 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

Accidents and incidents were recorded in paper format and also recorded electronically. Themes and trends and lessons learnt were looked for as incidents occurred through management analysis. The interim manager told us, “We do a clinical analysis as well as a daily stand up meeting with heads of department and a huddle in the afternoon with staff. We use this to share any learning with the team.”

We asked for an example where staff had identified a theme or trend and action had been taken and were told, “[Resident name] kept wheeling himself to the bathroom as he wished to remain independent, but then falling trying to transfer onto the toilet. We have put a sensor on his wheelchair seat which alerts staff if he tries to do this and they can go an assist.”

Accidents and incidents were also discussed during monthly clinical governance meetings.

The service 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.

When people expressed an interest in moving into the service a pre-assessment was completed prior to a place being offered. The pre-assessment was carried out face to face with the person either in their own home or in hospital if needed. Following this the person was discussed within the team at Tandridge Heights to check the person’s needs could be met, there was appropriate staffing in place and any equipment which may be needed (such as an alarm mat). Senior management told us a new form had been developed which was to be rolled out across the provider’s services. This included additional questions about a person’s needs to help ensure any transition into Tandridge Heights was carried out smoothly and safely.

Staff worked 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.

A recent local authority visit did not highlight any continued safeguarding concerns, and we also did not find any concerns during our visit. Staff told us they would be comfortable reporting poor practice to management.

Staff were also able to tell us what they would consider a potential concern. They told us, “You can look at bruises and aggressiveness because they could be scared about something or being shy. First, I’ll talk to my colleague because I am new here, then my supervisor and line manager. Or if it’s something urgent you call 111 or 999” and “Physical abuse. Hitting and punching a resident and slapping them because you don’t have the patience. I would report it to the manager and then I’d have to go above.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. We found all applications had been made to ensure people’s rights were respected and lawful.

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

Risks to people’s general health and wellbeing were not always managed safely. For example, it was noted in a person’s care plan they were at risk of experiencing constipation and yet, staff were not monitoring their bowel movements consistently in order to identify if they required health care professional input or medication. One person’s elimination care plan stated, ‘if any signs of constipation or abdominal distension are noted this is to be reported to the nurse in charge and GP.’ From their daily records over a period of 14 days there were only 3 occasions when staff had recorded information about whether they had opened their bowels or not. Records indicated they had not opened their bowels on 6 consecutive days, no actions were recorded. Another person was prescribed regular medication for constipation, and staff had only made records on 2 days relating to their bowel movement. There was a period of 5 days when staff had not recorded whether they had opened their bowels or not. This meant there was a risk people were not receiving appropriate treatment to prevent constipation.

People were not always protected from risk of avoidable infections and from the risk of choking. For example, a person was on a mince and moist diet and yet their choking risk assessment stated they were at low risk of choking. A person had a catheter and staff needed to check and empty the bag regularly. A risk assessment had not been completed providing information for staff on signs to look out for to alert them to issues and when to escalate their concerns. During a four-week period staff had recorded on 57 occasions when they emptied the bag, but on 41 of those they had not recorded the colour of the urine. Where records were complete the urine was noted as dark, brown and red with blood, there were no actions recorded following these observations. Another person had a catheter and their care plan stated that staff should report and record any concerns regarding their catheter to the nurse on duty and yet, upon review of their daily notes staff had not recorded on 33 of the 51 occasions the colour of the urine. Where records were complete the urine was noted as red with blood, orange/red and dark there were no actions recorded following these observations. This meant people were at risk of a medical emergency and staff could not detect issues or health conditions early enough to prevent it.

A person was recorded as having a low mood and expressing thoughts of harming themselves, yet there was no risk assessment in relation to this. Without a risk assessment management could not be assured staff would respond appropriately or know when to escalate concerns and involve the relevant professionals. In addition, this person lived with diabetes yet there was no information for staff around what to do should their blood sugar levels became too high or too low. This person’s respiratory care plan stated staff should carry out hourly checks on them as they suffered with respiratory condition, yet their daily records showed that staff were only checking them every 4 hours. This meant this person was at risk of avoidable harm.

Although we identified concerns, feedback from people was that they felt safe with staff and some people showed us they wore a pendant alarm which they could use to alert staff if they needed them quickly. Where people required support from staff to move, they said they felt staff carried out this aspect of their care in a competent way. A relative told us, “Yes, I feel she’s safe. In terms of security, there’s always people about. The staff all seem good and attentive.”

Some people’s care plans which were detailed and clear for staff. This included where 1 person could become anxious due to noise from others and the way in which staff could help calm them and another person who was at high risk of falling and how often staff needed to monitor them. People prone to skin breakdown were provided with pressure-relieving equipment to help prevent this.

Staff did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe and effective care.

During the inspection we observed some examples of environmental hazards and unsafe practice. There were trip hazards in corridors, and security and safety was concern. A door was left open to one area which contained equipment including slings used to support people to transfer, an unlocked fuse board and unlocked key cabinets with keys contained within it. The room floor was soiled. This meant anyone without authority could access the keys or people put at risk of harm.

The laundry room in the service was small and cluttered. People’s clothing were hung over laundry bins and balanced around the sink area. Soiled laundry overwhelmed the space and staff did not have space to work comfortably and ensure people’s belongings were respectfully handled.

Other aspects of the building were safely monitored and suitable for people. This included checking the water temperatures (to avoid the risk of Legionella), completing electrical and gas safety checks as well as carrying out routine fire safety systems.

Management did not always make sure there were enough suitably deployed qualified, skilled and experienced staff. They did not always work together well to provide care that met people’s individual needs in a timely manner.

Although some people told us they did not usually have to wait long for staff, we identified areas of the building where staff deployment could be improved. Throughout our visit, it was often difficult to locate a member of staff when needed.

Feedback about staffing levels was mixed and our observations reflected this. Some people said support was generally prompt, while others told us they had to wait for help. Comments we received included, “Usually I don’t wait long, although there are times when you do. It depends how many people they (staff) are dealing with”, “You just have to ring the bell and someone is with you pretty quickly”, “That is a bone of contention. You might be lucky, but I have waited anything up to half an hour”, “They are there when you need them” and “I don’t think there are enough staff up here. The carers are lovely and they do what they can, but it’s very difficult for them, especially when they go on their breaks.”

Relatives also shared mixed experiences. One relative told us their family member required support from 2 staff, particularly in the mornings, which was not always available. Another relative told us their family member had an adverse incident with another person living at the service. They felt this incident may not have occurred if sufficient staff had been available at the time. Feedback regarding staffing levels included, “There are not enough staff, especially on Sundays. Sometimes it feels very quiet here. You just don’t see anyone—they are not visible” and “I feel there are not enough staff to check on people with extra needs. The lack of staff means they (staff) only have time to complete basic tasks.” However, some relatives told us they had no concerns about staffing levels.

Staff views were also inconsistent. Staff told us, “There are enough staff, although some days can be very busy”, “Staffing becomes difficult during breaks, sometimes leaving only 1 staff member on the floor. But there is a whole-home approach, and nurses are willing to help” and “We are 5 carers. Ideally, I think it should be 6.”

During our visit, we observed 1 person still in bed, without having personal care at 11:30am and heard them asking the nurse, “I would like to get out of bed. I’ve been waiting ages.” We also observed 2 people sitting in 1 lounge on their own and a staff member told us, “They can’t be left on their own.” Eight minutes later these people were still on their own. Staff also said they did not always have time to offer people baths or showers, with 1 staff member saying, “Personal care is delayed or not done” and our review of people’s daily records supported this. We found from the review of 12 people’s records over a 14-day period, only 1 person had a shower on 3 separate occasions. Everyone else had only received a full body wash or care in bed. This demonstrated a need for management to review staffing levels and staff deployment to ensure people received care and support in a timely manner and in line with their needs.

Staff felt the training and induction was positive. One staff member told us, “Although I wasn’t new to care, I had 3 full days of training and then almost 1 week of shadowing a staff member already working here. I was confident by the time I had done this.” Another staff said, “We have in-house face to face training and online.” Relative’s felt staff were competent in their role. A relative said, “I think the regular staff most certainly know what they are doing and are adequately trained.”

Staff were recruited through robust processes. Staff were required to provide a full employment history, references and their fitness for the role. In addition, all staff underwent a Disclosure and Barring Services check (DBS) prior to working at the service. This helped ensure they were suitable to work in the care industry.

Management did not assess or manage the risk of infection.

Whilst the service initially appeared clean and hygienic we identified concerns and poor practices. For example, there were parts of the service which smelled strongly of urine, particularly in some people’s bedrooms. In addition, in the sluice rooms (room for clinical waste disposal and cleaning equipment) we found on the ground floor one had no hand soap for the handwashing sink as well as a rusty toilet seat in the clean equipment rack. In another room, the sink was unclean with debris in the plug area. On the first floor there was a toilet seat in the (clean) drying rack splattered with dried faeces.

People’s immediate environment was not hygienic, and this meant they were at risk of avoidable infections and there was a lack of dignity for them. For example, in 1 person’s bedroom their toilet as well as their armchair were heavily stained, with the fabric on the armchair degraded. In another person’s room their bed rails had splash marks on them, there was rubbish on the floor of their bathroom and a small faeces stain on the tiles behind their sink tap. A clean continence pad had been left out with their urine bottle and catheter tubing sitting on top. These were all next to their toilet brush. There was nothing to store their toiletries in, so their bottles and creams were also sitting on the back of the toilet. A further person had their sling hanging in their bathroom which smelled strongly or urine. Other people’s bedrooms and bathrooms had built up grime and limescale in their showers or toilet seat hinges.

We fed our concerns back to senior management during our visit and they told us following our inspection housekeepers from the region were all undertaking a deep clean of the service to address the issues found. Following our visit an incident report was completed in relation to housekeeping and infection control within the service with identified actions to be taken by the management.

We observed some people’s continence pads were left out of their packets exposed to the air. This left them exposed to the atmosphere, dust or moisture, which increased the risk of infection, particularly for people who are vulnerable or have broken skin.

Staff members told us they didn’t feel there was enough staff to maintain the cleanliness and hygiene of the service. They told us staffing numbers were inconsistent and this impacted on the service.

We also found people were not being provided with regular opportunities for a shower or bath as our review of 12 people’s daily notes over a period of 14 days found that people were received full body washes only. For people with compromised immune systems, such as the elderly or those with chronic illnesses, poor hygiene can lead to more frequent and severe infections.

In contrast to our observations we did receive some positive feedback about the cleanliness and the environment.

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

Staff were not following safe medicines management or administration practices. We observed the morning medicines round on the ground floor taking excessively long, starting at around 08:30 and still ongoing at 12:10. As a result, 1 person received their 08:00 medicines at 11:30. This meant a risk that morning and lunchtime medicines could be administered too close together. In addition, Medicine Administration Records (MAR) were not accurate. Staff signed the MAR as if this person’s medicines were given at 08:00 when they were administered at 11:30. This same person was prescribed liquid Paracetamol 3 times a day and we observed them taking only half of the prescribed dose, yet staff signed the MAR to indicate that the full dose had been given.

People on time critical medicines (such as Parkinson’s medicines) did not have the exact administration time recorded on their MAR. This meant if a different staff member carried out the next medicine round there was no way of them knowing whether they were giving the next dosage in line with the prescription instructions for example, within the right timescales.

Medicines were not stored safely as staff were not checking the temperature of the fridges in clinical rooms robustly to ensure medicines remained safe and effective. We found 2 fridges were showing the temperature was 15 degrees or above (5 degrees above the safe temperature) and as such medicines or the effectiveness of the medicines may have been compromised. There was no record that staff were resetting the thermometers after each reading and in 1 fridge we found Insulin which should be stored between 2 and 8 degrees until opened. We asked staff to contact the pharmacy for advice on what action they should take in relation to this. Management provided us with a copy of the pharmacy response following our inspection.

Further concerns were identified where 1 person was receiving 2 of their medicines, which should be given 30 minutes apart, at the same time. This meant the medicine may not be as effective, any side effects may be increased, and people were put at risk of avoidable harm. People on antipsychotic medicines, those to treat some mental health conditions, had not had these reviewed for some time. This is important to ensure the medication remains effective for the person’s current needs and to monitor for any side effects. Of the 14 people on these types of medicines, 5 had not had reviews since 2023 or 2024.

Other medicines and prescribed creams did not have sufficient information for staff. For example, 1 person’s prescribed cream instructions were, ‘use 1 pump daily’ without any information on the location or how to apply. Another person had a PRN (as and when) guidance for an injectable medicine but they were also prescribed the oral version of the medicine. A further person was prescribed a cream that presented a risk for women of childbearing age, but there was no warning for this medicine being administered by female staff.

People and relative’s felt they received the medicines they needed with 1 relative telling us, “I have no concerns about medication” and another saying, “No missed meds as far as I’m aware.”