Hebburn Court 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 inadequate. At this assessment the rating has changed to 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.

This service scored 59 (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 ensure good practice.

The provider had improved the systems for logging and investigating falls, incidents, accidents and safeguarding concerns. These were now being completed consistently and the accuracy of recording was better than at the last inspection. The provider also now had a consistent approach to analysing concerns to identify potential trends. However, the analysis needed to be more in-depth, to enable the provider to act and learn lessons effectively when things went wrong.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There had been no new admissions to the home since our last inspection. Although care plans and risk assessments had been reviewed and re-written, they needed further development so they contained accurate information which fully reflected people’s current needs.

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 inspection, safeguarding concerns were now being reported and investigated in a timely way.

Relatives confirmed they felt their family members were now safe at the home. One relative told us, “I feel my [family member] is 100% safe with the staff.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests (BI) and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

The provider was meeting the requirements of the MCA. DoLs authorisations had been approved or applied for. The provider had developed a DoLs matrix to monitor the timely renewal of DoLs applications.

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.

Risk assessments had been completed, where required. However, some needed further development as the measures to reduce risk were not recorded clearly. Some risk assessments described how staff should respond to situations, rather than the measures needed to prevent harm. There was also still some conflicting information in care plans and risk assessments which the provider’s auditing systems had not identified.

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.

The provider had addressed the environmental concerns from the last inspection. This included repairing the lift, addressing the fire safety and electrical installation defects. Although the provider had made progress, fire drills and checks on fire equipment were not done frequently enough.

Consent for CCTV use had now been sought from people using the service.

The provider made sure there were enough qualified, skilled and experienced staff, whoreceived effective support, supervision and development. They worked together well to providesafe care that met people’s individual needs.

Due to reduced occupancy in the home, there were currently enough staff deployed to meet people’s needs in a timely way. Relatives and staff told us the current staffing levels were sufficient. Staff told us the provider had listened to their views and deployed an additional member of staff to help. Since our last inspection, new staff had been recruited safely.

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 tidy throughout, and domestic staff were visible completing their duties to maintain the environment. The provider had up to date infection prevention and control (IPC) policies and procedures. Staff had also completed training in promoting good IPC.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. At the last inspection medicines processes did not keep people safe. At this inspection improvements had been made which meant people’s experiences of medicines were better. Some areas of medicines practice required further time and work.

Medicines were stored securely with access to them restricted. Controlled drugs had documented checks. For medicines requiring storage in a fridge, records were kept of minimum and maximum temperatures. The ordering process for medicines had been improved which meant there was no overstocking of medicines or out of stock medicines.

Where medicines were recorded on handwritten medicines administration records (MARs), further details needed recording such as warnings and maximum doses to ensure that a complete record was made.

Medicines which were prescribed as and when required now had information to support staff in the safe use of these medicines. However, improvements were needed to record the effectiveness of these medicines. The manager had taken steps to improve the paperwork to help better recording of outcomes.

A review was needed for the use of topical medicines. Topical medicines include creams, ointments, and shampoos. Although these were in most cases prescribed on the MAR chart, risk assessments were in place and body maps informed staff where to use these items. Staff routinely used codes on the MAR chart which showed topicals were not being administered. No further action had been taken to confirm with the prescriber if these topicals were needed or could be stopped.

Improvements had been made in the recording and oversight of the use of thickeners. Thickeners are powders used to thicken fluids when a person is at risk of choking. More work was needed to ensure paperwork about thickeners had full person details and dates were recorded.

Governance arrangements including, training and audits had been improved. Where concerns were being identified, action plans were in place to support further improvements.