Hartshill 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 good. 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 56 (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. Staff did not always recognise and report safety events.

Risks we identified in the environment had not been identified and raised by staff internally. For example, some people identified at high risk of developing skin damage had pressure relieving mattresses on their beds. The red service light was illuminated on mattress pumps in 8 bedrooms indicating a service was due. Staff had not responded promptly to this, and people remained lying on mattresses which were potentially ineffective and not working as intended. Following our feedback the provider took immediate action to address the servicing issue.

Accidents involving individuals were recorded and reported. Managers analysed accidents to identify any trends or patterns and to ensure appropriate action had been taken to mitigate individual risks. Actions taken included referrals to other health and social care professionals, increased monitoring and the introduction of new equipment.

Where people demonstrated their anxiety or distress through their verbal and physical responses, staff had recorded these incidents. The manager was in the process of introducing an auditing tool to ensure risk management strategies were effective and any learning identified.

Staff told us changes in people’s care or staff practice were shared during handovers between shifts and through the electronic care planning system. One staff member told us, “All accidents are reported to the senior staff on shift and the accident form is filled in. The forms go to the manager who looks into things in case we need to change how we are providing care.” Another staff member explained, “If anything happens, such as a resident fell, we get updated at handover. You are told if anything has changed like you need to do more checks, or they have an alert mat.”

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.

Staff contacted external healthcare professionals when a need was identified. This included the GP and an advanced nurse practitioner. One person told us, “There is a GP practice nurse who comes every Thursday and so we can see her if we need to. She will write a prescription, or we can go on the list to see the GP.” Another person commented, “If I’m ill, I tell the staff, and they sort me out.” A relative confirmed, “[Name] does see a GP when needed. They do keep us in touch whenever [Name] goes to the hospital or sees the GP.”

An external healthcare professional confirmed recent improvements had been made in the timeliness of referrals and the incorporation of their advice into people’s planned care.

There were systems in place to ensure other healthcare professionals had information about people’s immediate risks to their health when they were admitted to hospital in an emergency. A senior member of staff confirmed if people were discharged from hospital with incomplete paperwork, they contacted the hospital to ensure all relevant information was handed over. This staff member explained, “We have a mostly good relationship with the hospital, and they share information with us before a new resident comes. That helps us start to plan what the new resident 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.

People told us they felt safe living at Hartshill and were confident they could share any concerns with staff or the management team. One person told us, “Yes, I think we’re safe here. If I was worried about anything, I would tell any of the staff or the floor manager.” Another person said, “I like it here they look after me very well. I’m safe here. I’m so safe I never have to close my room door.”

Staff had received safeguarding training and could describe circumstances that would prompt them to report a concern. One member of care staff said, “If there was a situation that I felt was unsafe, such as we could not follow the needs described in someone’s care plan, I would raise that as a safeguarding issue. That is company policy.” Another staff member explained, “Keeping the residents safe is a must. Anything, even if you’re not sure, is reported to the manager who will investigate it. We have to tell the safeguarding team and CQC. The manager is very good, they would deal with things straight away.” A third staff member described how they would escalate concerns to external organisations such as the local authority safeguarding team if they felt appropriate action had not been taken to keep people safe.

The manager understood their responsibility to report any safeguarding concerns to the local authority and us, CQC. Records demonstrated information had been shared appropriately to investigate and address any safeguarding referrals raised.

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. When people were identified as potentially being deprived of their liberty, applications were made to the authorising body as required. Processes were in place to ensure Deprivation of Liberty Safeguards (DoLS) were managed in accordance with legislative requirements.

The provider did not always work well with people to understand and manage risks.

Some care plans did not provide sufficient information for staff, to protect people from risks such as skin damage. This was especially important as there was a reliance on agency staff in the home, who may not be familiar with people’s needs.

One person with pressure injuries was not on a repositioning chart despite this being a risk mitigation action identified within their care plan. Records reflected prolonged periods throughout the day when they were left lying in the same position. Where other people were on repositioning charts, this was not always being actioned as set out in their care plan. This increased their risk of pressure injury.

Some people were at risk of dehydration and their fluid intake needed to be closely monitored. We found some people were not drinking enough to meet their recommended daily intake and, on some occasions, were not offered enough fluid to meet their target over a 24-hour period. We observed some inaccuracies in records, where fluids were recorded as taken, when they had not been.

However, some care plans and risk assessments were very detailed, providing individual information about how people liked to be supported to help them feel safe. These included risk reduction plans for clinical issues such as safe catheter care and where people received their food and fluids through a tube directly into their stomach. One person could demonstrate anxiety which could impact on their safety and that of others. There was clear guidance about how staff should respond to mitigate risks when the person became distressed.

Overall, people and their relatives’ felt risks were managed well. One relative told us their family member had experienced many falls before moving to Hartshill Care Home. This relative commented, “[Name] has alarms everywhere. They have an alarm on their chair and on the mat in their room so, if they get up, the staff are there.” Another relative told us their family member had been cared for in bed for a significant period before moving to Hartshill Care Home. Staff in the home were now encouraging them to be up for short periods, enabling them to engage and interact with others.

The deputy manager told us there was ongoing work to improve the information in people’s care records. Shortfalls in the care plans we reviewed were immediately addressed.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People were able to access areas in the home which had potential to cause them serious injury or harm. For example, the boiler room and the maintenance office were open and accessible and exposed people to significant risk from hot surfaces, chemicals and maintenance equipment. Chemicals used for cleaning were not always handled safely and in line with Control of Substances Hazardous to Health (COSHH) guidance. Cleaning products were accessible in communal areas of the home.

On 2 occasions we found thickener [prescribed to thicken fluids] left accessible to people, posing a risk of choking.

A large hot water urn installed in the dining room was extremely hot to the touch, creating a serious risk of burns. Although a risk assessment was in place, usage of the water urn did not accord with the risk management strategies reflected within the assessment.

We observed 1 person who was at significant risk as their bed had become damaged overnight and they remained in bed without the equipment recommended in their care plan. Staff had reported this promptly; however, we observed this was not prioritised and remained a risk throughout the first day of our inspection.

Fire safety was not well managed as we identified issues in the environment which impacted on people’s safety in the event of a fire. A hole in the ceiling in a store cupboard due to a water leak created a significant risk as a fire could quickly spread along the void in the open roof space. Excessive storage of unused equipment, and the lack of a robust process to remove rubbish created a hazardous environment which increased the risk of a fire spreading rapidly. Combustible items had been stored directly against electrical items generating heat and rubbish including empty cardboard boxes had been left in store areas together with other flammable items. A significant amount of cardboard had been stored in 1 corridor which was a designated fire exit and holes in some doors compromised their resistance to fire. We found an oxygen cylinder, which was not secured or stored in a cylinder cradle. This meant there was a risk the cylinder could fall over, thereby exacerbating fire risks. Fire safety checks had not identified the significant fire risks due to unsafe storage practices within the home.

The provider had not ensured water temperatures were always checked in line with their policy and procedures and records did not evidence water outlets in some unused bedrooms were regularly flushed. These actions minimise the risks of scalding and help prevent the build-up of bacteria thereby reducing the risk of Legionella.

The provider took immediate action to address our concerns and on the second day of our inspection we identified significant improvement in the management of environmental risks.

The deployment of staff did not always support safe care that met people’s individual needs.

We received mixed feedback from people and their relatives as to whether there were enough staff to respond in a timely way when they needed assistance. One person told us, “I have to shout and shout until they [care staff] come to move me. Then they say they need help and go off to get someone else. They don’t always come back." Another person said, “I try not to get up until later, as I get hungry, and there aren’t always enough staff to bring me breakfast when I want it.” Other people told us they did not have any concerns about staffing levels. Comments included: “Generally, there are enough staff but sometimes they are busy”, “Yes, I think that there are enough staff. They are well trained, and they know what they are doing” and “The weekends feel the same as during the week. The staff are well trained and good at their job.”

We spent time in communal lounges and saw staff were present and available. However, when an incident happened, or people needed additional support, staff moved from another area in the home, leaving people in that area at risk. For example, 2 people had been allocated funding for 1-to-1 staff support due to risks associated with their care. We found only 1 member of staff supporting both people as the other member of staff had been called to support others living in the home.

We discussed the deployment of staff with the manager who assured us they monitored care provision to ensure staffing levels were safe and reflective of people’s needs. They told us any identified need for extra staff would be immediately escalated to the provider.

Staff felt they had the support and training for their role and there were enough staff to provide the care outlined in people’s care plans. One staff member told us, “It can get very busy, and staffing can be tight, but we manage.” Another member of staff commented, “With 5 staff on the floor and a senior, that is a good number."

Systems were in place to check the suitability of staff before they commenced employment. These included obtaining references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer.

The provider did not always assess or manage the risk of infection. During our site visit, we observed various infection prevention and control (IPC) concerns.

We observed some areas of the home were unhygienic and unclean. Walls, furniture, floors and doors in bedrooms, communal areas, corridors, shower rooms and toilets were marked, stained and soiled.

Clinical waste was not always disposed of appropriately. The foot operated lid mechanism on some clinical waste bins was broken, and bins did not always have a clinical waste bin liner. This compromised good hand hygiene and increased the risk of cross infection to people living in the home.

Staff had recently received infection control training and were seen using gloves and aprons. However, glove dispensers did not always have gloves available in all sizes. Hand soap was not available at all handwashing sinks and some areas did not display guidance on how to wash your hands.

Some domestic staff could not explain what they needed to do in the event of an outbreak to reduce the risk of it spreading around the home.

Infection control checks had been completed by the manager, which did not identify some of the issues we found. Where concerns had been identified, there was not always a clear trail of actions taken to resolve them. The manager told us they were reviewing the content of infection control audits to ensure they covered all aspects of infection control within the home.

People and their relatives generally expressed no concerns about the cleanliness of the home. Comments included: “The home is kept very clean, and [Name’s] room is very clean” and “[Name’s] room is clean, they were cleaning it the other day while I was here, they did a great job.” However, 1 relative told us washing up was not always completed in a timely way and commented, “The cups are not clean enough; dirty cups with chips on.”

Clinical rooms and clinical equipment were clean and ready for use and sharps were disposed of in accordance with best practice guidelines.

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

People told us they received their medicines as prescribed and pain relief was generally available when they needed it.

Overall, medicines were managed, stored, administered and disposed of safely, in accordance with best practice guidance. Where people received their medicines via a patch applied directly to their skin, best practice guidelines were followed and application sites recorded on body maps. Processes ensured time critical medicines were administered at the times prescribed. However, we found improvement was needed to ensure staff had more detailed information about why ‘as required’ medicines had been prescribed and signs to indicate they should be administered.

People received their medicines from staff who had completed training in the safe handling and administration of medicines. Increased observations of staff practice had been introduced to ensure staff remained competent to manage and administer people’s medicines safely. The management team carried out regular checks of medicines to ensure people received their medicines as prescribed.