Heyberry House

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 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. Systems were in place to record and monitor accidents and incidents. Staff understood the process for reporting and recording events which occurred.

Incidents and accidents were reviewed on a regular basis by the manager and the provider. This enabled them to analyse trends, identify any lessons and how to prevent similar incidents occurring.

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. This included when people were admitted into and from hospital.

Family members felt confident people received consistent care. A family member told us, “I’m happy with [Heyberry House] and impressed with the care. I feel that [Name] is safe here and the staff are very kind with [Name] and with me.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Information explaining how people could raise concerns if they felt someone was being abused was clearly displayed. People told us they felt safe. comments included, “I feel safe here because I know they care,” “Yes, I feel safe here and it’s just lovely” and “I feel safe here and I’m glad I came [to live here].”

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. Staff received training and understood the actions they must take if they felt someone was being harmed or abused. Staff told us they were confident the management team would take appropriate action in response to concerns. One staff member commented, “I would report concerns immediately. I would report to management, they both are on the ball, and I know they would deal with it.”

Systems were in place to protect people from the risk of abuse. The provider shared concerns quickly and appropriately. Referrals had been made to the local authority safeguarding team when abuse had been suspected.

Some people were unable to consent to the care they received and were being deprived of their liberty through the deprivation of liberty safeguards (DoLS) framework. We reviewed the systems in place to ensure such restrictions were lawfully authorised. There was a new manager in post who was in the process of updating the providers systems, however we found any authorised restrictions had been appropriately assessed and were reflected in peoples care plans.

The provider 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. We identified shortfalls in the accuracy of a small number of risk assessments and care plans. This was for some people whose needs had recently changed. We were assured people received appropriate care, but care records needed to be updated to reflect this. We raised any shortfalls with the management team who took immediate action to address these.

Some staff were not accurately recording checks on pressure relieving equipment. Some people need pressure relieving mattresses and cushions to help protect delicate skin at risk of breakdown and to prevent the development of pressure sores. We checked the equipment and found it was set up safely and established nobody had experienced any deterioration in their skin integrity. However, we shared our findings with the manager who took prompt action to reaffirm the correct processes with staff and put in increased checks.

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

Routine checks on the environment and equipment were up to date, and certificates were in place to demonstrate this. The layout of the environment considered the needs of people living with dementia. For example, directional signage was used to assist people’s orientation around the building.

People were encouraged to personalise their bedrooms. One person commented, “It’s a nice place and I have a nice room.”

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.

Systems to recruit staff were safe and appropriate checks had been made before applicants were offered employment.

Staff received an induction and received the training they needed to provide safe care. This included training to support people with a learning disability and autistic people effectively. New staff were given sufficient time to learn their role before working independently. One staff member confirmed, “I had an induction and did shadow shifts.” Family members told us staff had the necessary skills and knowledge to provide safe care. One family member told us, “I do feel that the staff have the skills to look after mum properly.”

Staff told us, and we observed staffing levels were safe, and there were enough staff on duty to provide the care people needed. We did receive some feedback from staff about staffing levels at night, although staff did confirm they were always able to ensure people’s needs were met. We raised this and the provider assured us this was under review.

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.

The home was clean and well maintained. People told us, “It’s nice and clean” and “The cleaners are great and it’s kept lovely.” One room did have an unpleasant odour. We raised this and received assurance from the provider the flooring of the room was to be replaced.

There was enough personal protective equipment (PPE) throughout the service for staff to use when needed. Regular audits and checks were carried out to ensure high standards of cleanliness and working practices were maintained.

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

Storage of medicines was not sufficient when delivered from the pharmacy which meant medicines were not as securely stored as they should be. We were assured this was for a short period of time whilst waiting for a new monthly cycle of medicines to start, however a solution was needed. We raised this and the provider confirmed new and improved storage facilities had been identified within the building which mitigated any risk to people.

Some improvements were needed to ensure care plans were updated and detailed protocols were in place for all prescribed medicines to guide staff when to offer a person medicines which were to be administered on a ‘as required’ basis. We found some protocols lacked details and a small number were yet to be completed. Immediate action was taken by senior care staff to address any issues we raised. Systems were in place to ensure people were not at risk of receiving too much ‘as required’ medicines.

Staff involved people in planning, including when changes happened and people were encouraged to be as independent as they could be with regards to managing their own medicines. Where people were able to self-medicate, safe and secure storage facilities had been put in place and staff monitored the safety of this practice.

Where people needed support, staff ensured people received their medicines as prescribed. The provider ensured staff received appropriate training and there were ongoing checks made on their competency to safely administer medicines.