Haddon House Nursing 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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, and medicines management.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the home did not always focus on safety and lessons were not always learnt from incidents. During our assessment, the inspection team had to ask for specific actions from the provider to ensure risks were suitably mitigated. For example, the inspection team had to ask that immediate medical advice was sought after a person had missed a dose of a time critical anti-coagulant. While the provider responded to concerns once they were brought to their attention, the provider’s systems and processes to oversee risk and improve safety were not effective. This meant risks to health and safety remained unresolved.

A root cause analysis (RCA) tool was in place which aimed to support in understanding why an incident occurred, whether there were wider system failures and actions to be taken. However, we found this tool had not been fully embedded or used to ensure lessons were learned to improve safety. For example, following some recent medicine errors, an RCA completed identified ongoing medicine audits to monitor compliance as a preventative measure to ensure safety. However, during our assessment we identified significant concerns in relation to medicines management. This indicated the preventative measures identified through the RCA had not been effective in addressing medicine related concerns, and placed people at risk of harm.

The provider did not always work well with people and healthcare 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.

Care was not always planned and organised with people and their loved ones. Relatives we spoke with told us they had not been involved in reviews of people’s care. One told us, “We've had nothing since [person] has been there. We've had no reviews at all.” Furthermore, inconsistencies in care plans had potential to impact on continuity of care as those providing support would not have clear guidance to support people safely. For example, some care plans contained conflicting information about the consistency of food people were assessed as requiring to keep them safe.

However, some relatives shared positive examples of how staff through the transition into the service had alleviated pressures they had faced before receiving support from the service and subsequently improving their relationships with their loved ones.

The provider did not always work 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. The provider did not always share concerns quickly and appropriately.

People were not fully protected from the risk of potential abuse or neglect. During our first site visit, we saw 2 people who had visible wounds or bruises, however appropriate documentation to record how injuries had occurred, establish cause and ensure appropriate action was taken was not consistently in place. This included whether an injury may have resulted from potential abuse or neglect. Staff could not tell us how these injuries had occurred. Following our first site visit, the provider took immediate action to ensure documentation was in place, appropriate referrals to relevant professionals were made and investigations were commenced. During our second site visit we found improved consistency in wound and bruise records. This meant any potential safeguarding concerns would be more promptly identified and escalated.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that whilst DoLS were appropriately applied for and monitored, one person’s care plans referred to an unauthorised restriction to manage a specific behaviour. Leaders explained this was no longer a current need for the person, and the restriction was not in place, however daily care notes had referenced the potential use of the restriction less than 1 month prior to our assessment. The provider’s systems had not identified this and therefore failed to investigate or refer to relevant authorities. This placed the person at risk of being unlawfully restricted. The provider took immediate action following our first site visit to ensure any use of the restriction was removed from care records, and staff were aware this was not a current practice.

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

People were not safely supported to maintain their skin integrity. Records for people at high risk of skin breakdown provided inconsistent information and unclear guidance regarding frequency of repositioning. For example, one person’s skin integrity care plan stated they needed 4 hourly re-positioning in the day, but another care plan stated they needed 2 hourly repositioning in the day. This placed people at risk of not receiving adequate pressure relief, and increased risk pressure sores. Furthermore, some people had active pressure sores and needed regular repositioning to maintain their skin integrity. Records did not demonstrate people had been consistently repositioned as required.For example, records showed significant gaps of up to 10 hours between repositioning for one person who had a stage 2 pressure sore. This placed people at risk of further skin breakdown and health deterioration.

During our second site visit, the provider confirmed they would increase support at senior leader level and ensure clear accountability for overseeing improvements in skin integrity support for people.

Some other risks such as epilepsy management or catheter care were robustly assessed, and staff were supported by way of clear guidance to ensure people’s needs in these areas were managed safely.

The provider 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 care.

Equipment to support safe care was not always available or maintained. During our first site visit, a member of staff told us they had reported a person’s pressure mattress as it was flat, but no action had been taken. The inspection team checked the mattress which was deflated and displaying a low-pressure warning light. This meant the person was not receiving appropriate pressure relief. The inspection team reported to the leadership team again, and immediate action was taken to replace the mattress.

Staff also shared they had requested an additional stand aid, as sometimes people had to wait for it to be available before being able to support them. However as this was supplied, the existing stand aid had been removed leaving them in the same position. The inspection team reported to the leadership team who agreed to review.

Call bells were not consistently working during our second site visit. We tested this and found the upstairs call bells only alerted downstairs. This meant people were at risk of delayed support. We reported this to the leadership team who told us an engineer had been to repair the system but would seek further assistance to ensure the issue was resolved promptly.

However, the premises were secure, and people had access to a pleasant and well-kept outdoor space. Routine health and safety checks were carried out on the environment, and a refurbishment plan was in place. Feedback on the environment included, “Yes, it's fine. They've upgraded it a bit. The seating could be improved. They've made it more homely.” And “[Person’s] room is perfect.”

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.

Staff were not deployed effectively. The provider used a dependency tool to calculate safe staffing levels. Whilst numbers of staff were in line with the assessed needs of people, factors such as the layout of the environment, or supervision of communal spaces were not considered. During our first site visit we found communal lounges were not always supervised. This increased the risk of delayed support, or incidents occurring.

Feedback around staffing levels was mixed. Some relatives felt staffing levels were sufficient to meet people’s needs, with one relative confirming, “As far as I can see, staffing is fine.” Others felt there were times when staff were not always visible, or available. A relative told us, “Staffing is tight. There was only one carer where [person] is. No other members of staff. And the member of staff might disappear for 5 minutes and then come back.”

To improve staff deployment and ensure lounges were always supervised, the provider made arrangements to support people in the 3 downstairs lounges, rather than all 4 across the building. Although this resulted in improvement in ensuring communal spaces were consistently supervised during our second site visit, feedback about the impact of this on people’s experience was mixed. We shared this with the provider who told us they would keep this under review.
While staff had received appropriate training to support them in their roles, staff had not received regular ongoing support by way of regular one to one supervision. This limited opportunities to discuss practice and identify development needs.

The provider followed safe recruitment practices.

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.

During our first site visit, we found the clinic room to be unclean. The provider took action to deep clean this area, and improvements were observed during our second site visit. However, people’s overall environment was observed to be clean, and domestic staff were visible and observed to be maintaining standards of cleanliness throughout the service. People were observed to be washed and dressed in clean clothing.

Feedback from people and relatives about cleanliness and support to maintain personal hygiene was overall positive. One shared, “As far as I can see it. [Person] is clean, their clothes are clean, [person] seems neat and tidy.”

Staff were observed to follow best practice guidance in the use of personal protective equipment (PPE). Relevant policies and training were in place to support infection control.

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

People did not always receive their medicines as prescribed. One person’s electronic medicine administration record (eMAR) had shown a medicine was out of stock the day before our second site visit. Staff confirmed they had contacted the pharmacy to have this medicine delivered, but were told it would not arrive in time for their early morning dose. Staff had not taken all reasonable steps to ensure the medicine was on site in time, and during our second site visit we found the person had missed their early morning dose. This was a time critical anti-coagulant medicine which could have serious health risks if not taken. The inspection team had to push for staff to follow up, ensuring the person’s medicine was on site, and that immediate medical advice was sought for the person in regard to the missed medicine.

Medicines were not stored, monitored or managed safely. We found excessive stock of medicines at the service. This increased the risk of medicines deteriorating, expiring beforeuseor being selected and administered in error. There were medicines in stock which had no opening date, or expiry information recorded. This meant people were at risk of receiving medicines which were out of date, which could result in ineffective treatment or adverse effects.

Systems to oversee medicines were not effective in identifying and addressing medicines-related risks. For example, an August 2026 medicine audit had not been fully completed, and had failed to identify the concerns we picked up during our assessment. This placed people at risk of harm.

Policies relating to medicines storage, expiry-date management and repackaged medicines were not consistently followed in practice. For example, medicine cupboards were found unlocked which meant they could be accessed. We found food stored in the medicine’s fridge, which was not in line with recognised medicines storage practice. Medicines which were no longer in use had not been disposed of safely which increased the risk of discontinued medicines being administered. Stock levels had not been routinely reviewed so that medicines no longerrequired, or out of date, were removed promptly.This placed people at risk of harm.

During our second site visit, the provider confirmed they would increase support at senior leader level and ensure clear accountability for overseeing medicines at the service.