Handford House Care Home

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 inadequate. We found breaches of regulation in relation to staffing and safe care and treatment. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

The provider was no longer in breach of regulation in staffing and safe care and treatment. Improvements had been made in this key question and some were ongoing, they needed to be embedded in practice and sustained due to the concerns we had identified at our last assessment.

Improvements had been made in staffing, including training and support. The local authority had previously suspended placing people in the service until improvements had been made, they had now made the decision with the provider to accommodate people within the service. The provider needed to ensure safe staffing levels as the numbers of people living in the service increased.

Ongoing improvements were being made in how risks were being assessed, mitigated and learned from to reduce the risks of avoidable harm. Safeguarding concerns were reported appropriately and lessons learned. Infection control processes had been improved, these improvements needed to be maintained.

People received their medicines when they needed them and ongoing monitoring supported the management team to identify shortfalls and address them.

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 was improving in its ability to ensure a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and these were being reported. Systems were improving to show lessons were being learnt to identify and embed good practice. These improvements needed to fully embedded and sustained.

Since our last assessment, we found improvements in how the service learned lessons to improve the service. Improvements had been made in staff training and 1 to 1 staff supervision, where staff could discuss any concerns, receive feedback and identify training needs. The majority of staff told us how the culture in the service had improved and they were happy working in the service.

There was a duty of candour policy and procedure in place and records showed where incidents had happened, people and their relatives, where appropriate, were provided with an explanation of what happened, investigation outcomes, actions taken and an apology. This demonstrated an open approach to sharing information when things went wrong. However, we received feedback from a relative who felt they had not received detailed information about an incident despite meeting with a member of the management team. We suggested they arrange an appointment to discuss further if they were not satisfied with the explanation they had received.

Incidents and accidents, including falls and any skin damage, were analysed to identify any trends and patterns. Lessons were learned to reduce the risks of them happening again and these were shared with staff. Analysis also included comparisons to previous months, for example if they had reduced or increased.

Records of wounds were kept and analysed. Actions taken showed treatment was being provided, and referrals made where required, for example to a tissue viability nurse.

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.

Prior to moving into the service, a member of the management team undertook an assessment of the person’s needs to assess if the service could meet their needs. These were held in the person’s current place of residence, such as their home or hospital with the input of the person, their representative and other professionals involved in their care. Where it was not possible to undertake a needs assessment prior to moving in, such as if the person started using the service in an emergency, the needs assessment was undertaken as soon as possible. The needs assessments were used to inform the care plan and risk assessments when the person started to use the service, these were kept under review.

Where a person may require admission to hospital, the staff provided the required information to ensure they were aware of the person’s needs. People’s treatment received from health professionals was incorporated into their care plans to ensure consistency of care, and any guidance from other professionals was followed.

Improvements were being made, which needed to be embedded in practice and sustained. 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.

Since our last assessment, improvements had been made in the systems to keep people safe from abuse. At our last assessment we noted people sometimes entered other people’s bedrooms, when this was not wanted. During our second visit, we saw a person sleeping on their bed and another person was sleeping on a chair in their room. When we pointed this out to staff, they told us they were just about to do checks, and said the person who was in the chair often went into other’s rooms. They encouraged the person to come out of the room to give privacy.

At our last assessment we had noted gaps in staff training, this had been addressed. During this assessment staff had received training in safeguarding and understood their responsibilities. Notices were posted in the service to guide staff on actions they should take if they were concerned.

Staff had referred any concerns of abuse to the local authority safeguarding team, who are responsible for investigating abuse. Where required, the provider shared information with the safeguarding team, to assist with their enquiries. Where requested internal investigations were carried out and the findings shared with the safeguarding team.

Any safeguarding concerns were kept under review and analysis took place to identify any trends and patterns. Documentation showed lessons were learned to reduce future risks and these were shared with staff, for example in staff meetings and 1 to 1 supervision.

Improvements were being implemented which needed to be embedded and sustained in practice. The provider now worked with people to understand and manage risks. Staff now provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were records to show people’s blood sugars were being monitored where they had diabetes. However, these were not always being done in line with the guidance on the forms, for example, weekly. Once we pointed this out to the management team, actions were taken to check the remaining records and information was sent to the staff team to advise these must be done. The management told us they planned to hold a staff meeting with nursing staff to ensure they were aware of the importance of ensuring actions were taken.

Risks were assessed, such as if there was a risk of choking. Choking risks were reviewed and reported in the provider’s monthly clinical report. It was noted no choking events had happened in January to March 2025. Where people were at risk of choking, referrals were made, for example to the Speech and Language Therapy Team (SALT) and guidance was followed, such as the specific textures of fluids and food to reduce the risks of choking.

The risks of dehydration were assessed and staff were guided in the care plans how to reduce risks, this included signs and indicators of dehydration. The daily target of fluids were documented and how staff were to ensure fluids were accessible to people. Care plans were kept up to date, for example, a person’s records stated the date they had commenced antibiotics for a urine infection and that staff were to encourage fluids. A person’s records showed they had exceeded their target for 15 days. Another person’s records showed they had not met their fluid intake target; this was especially important due to their health condition requiring a good intake of fluids. This had been identified in the risk assessments and for staff to encourage and prompt fluids and the fluid charts to be monitored.

Systems were in place to assess and mitigate the risk of falls, including the use of equipment to alert staff when people attempted to walk independently when they were at risk of falling. A person’s care plan guided staff to remind the person to wear their footwear when mobilising.

People’s care plans included personal emergency evacuation plans (PEEPS) which provided guidance for staff in the support people required should the service need evacuating.

Risks were assessed and mitigated relating to the risk of developing pressure ulcers. This included the use of equipment and creams. Care plans identified if the person could independently move position or if they required regular support to reposition. Records were maintained to show where people received this support. Records of repositioning were being kept under review to assist the management team to identify where there were shortfalls and address them.

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

Since our last assessment, improvements had been made in the safety of the environment.

There was an ongoing programme of refurbishment and redecoration in the service. The environment was adapted to meet people’s needs and was safe and well maintained. Where risks were identified by staff this was recorded for the attention of the maintenance staff, who addressed the issues or external contractors were used where required. Where actions had been taken, this was documented. Regular checks of the environment were undertaken to monitor if there were any risks. Risk assessments provided guidance on how risks were to be mitigated and to keep everyone in the service safe. Stairs were not accessible to people using the service to reduce the risks of them falling down them.

People were safe in the environment, regular checks and servicing was undertaken in the environment and on the equipment used, for example fire safety, moving and handling equipment, window restrictors, electrical equipment, and gas safety checks. There were systems in place to reduce the risks of legionella in the water system.

People’s records included assessments on the support they required should the service need evacuating, such as in the event of a fire. Records of fire drills were maintained to ensure staff were aware of their responsibilities to keep themselves and people safe.

The provider’s contingency plan set out actions to be taken in emergency situations, such as a gas leak and flood.

Improvements had been made since our last assessment which needed to be embedded and sustained in practice. There were now 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.

At our last assessment, we found there were insufficient staff who were deployed and trained to meet people’s needs safely and effectively. We had received feedback from people, relatives and staff which identified concerns that staff were not always available when needed. The local authority had suspended placing people in the service. During this assessment, the management team told us the local authority had made a decision to place their customers in the service. There were reduced numbers of people living in the service, having 16 vacancies. We needed to be assured that improvements would be embedded and sustained, particularly if more people were to be moving into the service. The management team told us they would keep the staffing levels continuously under review.

We received more positive feedback relating to staff availability from people and relatives. However, 4 relatives said they had received information from their family members where they had to wait for staff support. The majority of staff told us they felt there were enough staff, with 2 staff saying there were not. We received concerns from a staff member and relatives about the staffing levels, however, the staffing rota and discussions with the management team demonstrated the planned staffing levels were maintained.

The provider was now monitoring call bell times to ensure people were supported by staff in a timely way. Staff meeting minutes showed staff were advised of ensuring call bells were responded to promptly and if staff needed to return if they were busy, they were to tell the person when they were returning and do so.

Staff vacancies were being covered by existing staff, bank staff and agency staff. Vacancies were being actively recruited to, including a night nurse vacancy. Whilst this post was being recruited to, there were some nights when there was 1 nurse on duty. The manager told us forward planning was in place to ensure nurses were available when needed, such as if a person was at the end of their life. The manager or, for example the clinical lead was on call and could attend the service where required. Agency staff were used to support 5 people who required 1 to 1 support from staff. A person told us this was usually the same person who was known to them.

Records of staff recruitment showed the appropriate checks were made, including, Disclosure and Barring Service (DBS) checks which provide information including details about convictions and cautions held on the Police National Computer. This information helped employers make safer recruitment decisions.

Improvements had been made in staff training, with this being monitored to ensure staff were undertaking their on-line required training. In addition, more face to face training was being delivered, the manager told us this training was being tailor made to the service. Improvements had been made in the provision of 1 to 1 staff supervision to provide them with a forum to receive feedback, discuss any concerns and to identify any training needs they had.

Since our last assessment improvements had been made which needed to be embedded and sustained in practice. 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.

At our last assessment we identified shortfalls in the infection control and prevention (IPC) in the home and we had received concerns about how the provider had managed an infection outbreak. At this assessment, improvements had been made in the cleanliness of the service. The home was visibly clean throughout. Toilet brushes and holders had been replaced and were now stored so the brushes were not sitting in unclean water. Toilet rolls were in the covered toilet roll dispensers, rather than on the grab rails. The kitchenettes were clean, and a staff member told us they were routinely cleaned.

We received feedback from people and relatives confirming improvements in the cleanliness of the service. However, we received a concern from a relative regarding a smell in their family member’s toilet. We checked this during our visit and could not detect any unpleasant odours throughout the service.

Infections were reported and kept under review to ensure the appropriate treatment and precautions were undertaken.

Personal protective equipment (PPE), including gloves and aprons, were available and used by staff as required. Staff were monitored to check they were wearing PPE and hand washing audits were undertaken to reduce the risks of cross infection. Staff received training in infection control and prevention (IPC).

People’s care plans included guidance for staff relating to specific IPC processes which related to their health and wellbeing and equipment used. A staff member told us how hoists were cleaned after each use to reduce cross infection. Cleaning schedules were in place which identified the areas to be cleaned in the service and the frequency required. These were signed by staff to show the cleaning had been undertaken as required. Cleaning and IPC processes were monitored by the head housekeeper and actions taken if shortfalls identified. The head housekeeper was an IPC champion and had attended enhanced training. They told us they had learned a lot from their training and incorporated into their daily work and shared their learning with the staff team.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems in place reduced the risks of people not receiving their medicines where required. Audits and monitoring of medicines assisted the provider to identify shortfalls and address them. This included any errors with the administration of medicines. Lessons were learned and actions taken, including reflective accounts by staff and re-training where required.

Medicines were stored safely, including routine temperature checks. Where people were prescribed medicines to be taken as required (PRN), there were protocols in place to guide staff when these should be considered and any risks associated with these medicines. Records were kept which showed when PRN medicine was administered and if they had been effective. Where people required their medicines to be given hidden, such as in food, there was documentation in place to show this decision had been made in the person’s best interests and that it was safe to give people their medicines in this way, for example from the GP and pharmacy. Records demonstrated where on the body medicines in the form of patches had been placed.

People’s care plans included their prescribed medicines, what they were for and any risks associated with the medicines. Any time specific medicines were identified in their care plan, including specific guidance when medicines were to be taken, for example, 30 minutes before food. Care plans included the dates of medicines reviews undertaken by the GP and any changes.

Risk assessments were in place relating to flammable emollients in people’s care plans. Where people required support with topical medicines, including creams, records were maintained when these had been administered. These were kept under review daily to support the management team to identify shortfalls and address them.

Staff responsible for administering medicines had been trained and their competency was checked.