Archived: 142 Petts Hill 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.

The last rating for this key question was requires improvement. 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 people being safeguarded from abuse, and safe care and treatment.

The risks associated with people’s care were not always being managed and there was not always sufficiently qualified and trained staff deployed to support people in a safe way. People’s medicines were not always being managed in a safe way. People were not protected from the risk of abuse. Incidents were not being analysed to reduce risk of reoccurrence. Infection control was poor, and the provider had no oversight of the risk of spread of infection.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last assessment, we identified that oversight of accidents and incidents were not robust. At this assessment we continued to find concerns.

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 provider did not have effective systems in place in order to learn from incidents, accidents, complaints or other adverse events. Records relating to people’s care had not been completed since February 2023, this meant the provider had no way of analysing information to ensure they were safely and effectively supported.

Following our assessment, we requested the provider send us all monitoring checks of the service and the training records for all staff; however, we did not receive these.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

A staff member told us that a person they supported had regular involvement from professionals in a local health community team, however we found no documentation of this in the person’s file. This meant the person was at risk of not receiving the correct and safe care and support from staff.

People were at risk of not being safely support by staff because the provider did not establish and maintain safe systems of care. They did not assess, manage or monitor people’s safety effectively. People’s needs were not assessed in a holistic manner and care plans lacked important information about how to minimise risks associated with people’s care. For example, a care plan we read contained no information about the person’s specific healthcare needs and/or how staff should support them. A staff member we spoke with had little knowledge about the person’s needs.

At our last inspection, we found that people were at risk of harm and abuse, due to a lack of robust management of people’s health needs. At this assessment we found this continued.

People were not always protected by the providers safeguarding processes in order for them to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider did not work in partnership with people and healthcare partners to support their understanding of what maintaining their safety meant to them and how to achieve it. For example, the provider did not always promptly share concerns with the local authority safeguarding team in line with their statutory obligations.

The provider used restrictive practices including locking the kitchen door at night, this meant that the person wanting a cigarette had to ask staff to unlock the door to get a light.

A staff member told us they had undertaken safeguarding training recently, however when we spoke with a member of staff they were not aware of how to safely support people who needed additional support in line with their individual diagnosis.

Following our assessment we asked the provider to send us records to confirm all staff had received safeguarding training, however this was not received. Therefore, we could not be assured all staff were suitably trained.

The provider explained that the local authority had concerns in relation to how Power of Attorney (POA) was being managed. The provider had not alerted the local authority to inform them that they were the POA for a person using the service. The process was being changed to ensure the best interests of the person were considered; however, the provider was not aware of the reason for concerns raised by the local authority in relation to the best interests of the person, nor how this could be a conflict of interest.

People were not always supported in line with the Mental Capacity Act 2005 to ensure decisions had been made in people’s best interests or in the least restrictive way. For example, the provider had made decisions about people’s care without consulting all the relevant people who should be involved. This had led to restrictions on people’s freedoms and human right and some decisions had exposed people to the risk of abuse.

The provider failed to follow the concerns up such as notifying the Care Quality Commission (CQC). The impact of this was the person missed his medicine as prescribed.

At our last assessment we identified that risks to people’s health and wellbeing had not been identified and mitigated, at this assessment we found the same concerns.

The provider did not 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.

Individual risk assessments were not always detailed enough or personalised. They did not always include personalised information about the risk to the person, their perspective and capacity relating to these risks.

Risk assessments were out of date and for one person who chose to smoke in their bedroom, the risk assessment did not include the person’s wishes and consent in relation to the risks. The provider used restrictive practices including locking the kitchen door at night, this meant that the person wanting a cigarette had to ask staff to unlock the door to get a light.

A staff member we spoke with was not aware of a person’s condition and how best to support the person in situations when they experienced challenges. We asked for specific training records to show the training provided to staff to support people with their condition, these were not provided as part of our inspection. Therefore, we could not be assured they were in place and people’s needs were safely being met.

People did not live in an environment that was routinely and effectively checked to ensure its safety. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Safety checks including fire, electrical and gas checks were carried out to ensure equipment was safe for use. However, health safety and infection control checks had been ineffective as they failed to identify the environment was not always safe and clean.

On entering the property, we saw tubs of paint in the porch, the carpet on the stairs was heavily stained, and wallpaper was coming away from the wall on the upper level of the stairs from a damp area.

The living room area where the TV was positioned had extension cables with lots of wires coming from the cables, these were a trip hazard for people trying to access the garden from the lounge areas and could be a be a fire hazard. In addition to this, the air fryer in the kitchen had two boxes of matches and a packet of cigarettes in it. The provider told us that whilst people living at the service had access to the kitchen during the day they did not use the air fryer.

There was a lot of items for example duvets and blankets piled up on top of drawers in the living room.

The provider did not 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 work together with other professionals well to provide safe care that met people’s individual needs.

The rota showed one staff member was allocated to work a significant number of hours during the day and a night duty. The combination of the number of hours worked and the pattern of shifts posed a risk of the staff member being tired and therefore not being able to effectively deliver safe care and support. This could put people at risk of receiving unsafe care and support.

A staff member we spoke with told us they did not have the knowledge and written information in how to support a person to keep them safe.

People were not protected by safe recruitment practices to ensure people were supported by suitable staff. Staff files did not hold all the information required. For example, for a staff member there was no completed application form, no evidence of a Disclosure and Barring Service (DBS) interview notes, induction, or supervision. This puts people at risk of being supported by staff who were not safely vetted and potentially being unsuitable to support vulnerable people. We raised this with the provider, but they were unable to locate these.

We asked for supervision records, but these could not be provided, this meant that we were not assured staff were receiving the support and development to carry out their role and meet people’s needs safely.

Staff had not had sufficient training to meet people’s needs. This included support around people’s mental health conditions which is one condition of the providers registration and one of the primary needs of people living at the home.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider employed a cleaner one day a week; however the premises had a strong mal odour of urine throughout, this included the patio area in the garden where we found a yellow clinical waste bag which was full, this should have been correctly stored in a designated clinical waste bin. This meant that the provider was not following the safe disposal of clinical waste which could pose risks to service users and the environment.

The downstairs living rooms were dark and had a strong malodour of urine, the environment did not present homely, clean or comfortable environment for people to live in.

The provider did not follow environmental best practice and guidance in respect of food standards.

The kitchen was dirty, and food stored in cupboards and in the fridge and freezer was sometimes difficult to decipher the contents. Examples included take away plastic boxes of food with food that was not labelled to show contents or dates when it was stored and needed to be used by.

Meat in the fridge and freezer was unlabelled and some of the contents difficult to tell what the meat was. The fridge temperature gauge read 12 degrees Celsius on the day of our inspection. The Food Standards Agency states a fridge temperature should be no higher than 5 degrees centigrade to help stop harmful bacteria growing in food. This meant the provider could not be assured the food was safe for people using the service to eat putting them at risk of ill health.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We observed a medicines error on the day of our inspection, when we alerted the provider, we were not assured they were aware of their own policy and process for such incidents. People’s medicines were not administered safely. On the day of our assessment whilst reviewing the medicines management system we found for one person at 14.00pm, we noted their 8:00am tablets were still in the medicine pack and had not been administered. The 08:00am medication was significantly important to support their mental health, which meant the person could have been at risk of a relapse in their condition. When we informed the provider they said, “I will administer now.” This meant the person did not receive their medicines on time and as prescribed and put the person at risk of missing their medicines.

The provider failed to follow the concerns up such as notifying the Care Quality Commission (CQC). The impact of this was the person missed his medicine as prescribed.

We found insulin and further boxes stuck frozen to the back of the fridge in the kitchen, the person who required these was in hospital at the time of our inspection. When we expressed our concerns to the provider, they were not aware of the seriousness of the unsafe storage. The fridge was accessible to all and medicines stored in the fridge could be inappropriately used or administered. Following us raising this with the provider these were removed on the day by the provider.

A care plan we looked at did not have detailed information of how a person needed to be supported with their medicines, it did not have detail of medicines prescribed. We were not provided with a risk assessment for non-administration of medicines or a protocol.

We asked the provider to send us their audits for medicines; we did not receive this information. We asked the provider to send us their medicine policy procedure and medicine competency checks for all staff; we did not receive this information. We asked the provider to send us their medicine policy procedure and medicine competency checks for all staff; we did not receive this information.

This meant there was no system for the safe management and oversight of medicines in place and people were at risk of receiving their medicines safely.

The provider had not ensured staff were competent in their roles. Medicines administration competency checks had not been completed. We were therefore not assured people would receive safe care from suitably skilled staff.