Highwood Mill Extra Care Scheme

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 remained 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 and the way people’s medicines were managed safely.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. While staff and managers were open about incidents, lessons were not consistently embedded. Records showed that medication errors were recurring themes but that the provider had not identified the trend and learned lessons. The provider had started implementing spot checks and reactional supervision, but these improvements were recent and not yet fully embedded to improve practices as medication errors continued to be recorded. Staff told us they welcomed clearer guidance and oversight, but systems for monitoring trends and sharing learning were still developing.

The provider did not always work well with partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. There were systems to support safe care, but they were not always robust. Care plans and risk assessments were in place for most people, and managers worked with the local authority when needs changed. However, gaps in oversight meant some risks were not identified promptly. For example, although the call bell system was not the responsibility of Care Outlook, call bell monitoring faults relied on external reporting, and delays in resolving technical faults affected responsiveness. This affected the providers ability to respond to risks and trends that timely call bell monitoring can provide. The provider had introduced weekly audits and escalation processes, which were beginning to improve consistency.

Staff understood safeguarding principles and were clear about when to raise alerts. Records showed that concerns were reported to the local authority and CQC, and safeguarding investigations were completed. People told us they felt safe with staff. However, the volume of medication errors, and the providers failure to identify trends, indicated that auditing systems were not always effective. The provider had strengthened training and introduced competency checks, but these changes were still embedding.

Staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). 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 MCA. People were protected when issues around capacity had been identified. Mental capacity assessments had been conducted and recorded to determine whether they had capacity to make specific decisions about their care. Deprivation of Liberty Safeguards (DoLS) applications were completed appropriately and in people’s best interests with minimal restrictions. Where people had a DoLS in place, conditions to their authorisations were being met.

People were not always fully involved in managing risks to their safety and the safety of others. While care plans included risk assessments, these were not consistently reviewed or updated to reflect changes in people’s needs. We found examples where doors to flats were left unlocked and medication was not stored securely. This meant that other people living in the service, including those with dementia, could access medicines that were not prescribed for them, creating a potential risk of harm.

People told us they were not always informed about changes or delays in care, and staff confirmed that communication about risk management was inconsistent. The provider had started introducing tools to support people with communication needs, but these were not yet embedded in practice.

The environment was generally safe and well maintained. Weekly checks were carried out by key workers to identify hazards and ensure cleanliness. Risk assessments for individual flats were in place, and staff monitored food safety and infection control. People told us they felt comfortable in their homes and appreciated adaptations such as adjustable kitchen units.

There was good collaboration between the housing provider and the care team, working together to rectify maintenance issues like the lift for example.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

They did not always work together well to provide safe care that met people’s individual needs. Staffing levels were not always sufficient to meet people’s needs safely. At night, one care worker was responsible for the support of people, which staff and managers described as unsafe. There was a lack of a robust risk assessment in place to mitigate any risks while staffing was being discussed with the extra care team.

Recruitment was ongoing, and agency staff were used, but this created challenges in continuity and oversight. A person told us, “If only they had more staff.”

The provider used agency staff to fill gaps in rotas. The provider asked for a staff profile from the agencies they used so that they could appropriately match staff to people. We found that the provider did not always know who was being sent which meant the provider could not be assured they were deploying staff effectively.

Staff followed infection prevention and control (IPC) procedures, and audits were completed. PPE was available and used appropriately during our visit. The provider had an IPC policy and had completed IPC risk assessments. People told us staff maintained good hygiene. Although some earlier complaints indicated that PPE was not always worn, the provider had to reinforce expectations through team meetings, and this improved practice.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not consistently involved in planning. The provider had a framework of competency checks in place but these were not consistently effective. Medicine practices were a concern at the last inspection and shortfalls still remain.

There were repeated errors, including missed doses. MAR records were incomplete, and audits were only recently introduced. As a result of incomplete records, the provider was not assured if people had received their medicines in a timely fashion. The provider did not have safe systems around ensuring people had enough medicines. PRN (As required medicines) protocols were not in place. This meant there was no clear, individualised instructions for staff to follow and these actions were not recorded appropriately to ensure they were consistency administered. Systems in place for ensuring people did not run out of medicines were not robust. The provider told us that there were times when people’s medicine’s ran out but no harm was caused following discussions with the GP. The provider told us they were trying to accommodate different people’s needs but acknowledged that action was needed. The provider had started medication trackers and staff competency checks, but these improvements were recent and had not yet reduced the potential risk of harm or been embedded in practice.