Hayes Park 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 inspection rating inspection (published 8 March 2022) we rated this key question Good. At this inspection, 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. The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 53 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager attended daily staff handover meetings during the week and used this as an opportunity to share any learning opportunities with staff. For example, accidents, incidents, complaints, concerns and whistleblowing events were investigated by the registered manager and any identified learning points were shared with staff.

Staff daily handover, team meeting records and feedback from staff confirmed the registered manager had a positive and transparent learning approach. A staff member said, “Lessons learnt are discussed in meetings, training may be identified or other action. The manger always tells us in handover meetings, they always inform us.”

People and relatives told us there was good communication systems and felt involved and informed of any accidents and incidents. They told us they were sufficiently assured actions were taken to make improvements.

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.

The provider had safe systems and processes that assessed people’s needs before they transferred to the service. The registered manager told us, and staff confirmed, how an initial new placement referral was discussed in staff handover meetings to ensure the service could meet the needs of the person. This was then followed up by a face to face assessment with the person, relatives and other relevant people such as the current care provider.

Examples of pre-assessments reviewed found these to be well completed, enabling any staff training or resource implications to be arranged and completed prior to the person moving to the service.

People and relatives confirmed they had been involved in a pre-assessment before moving to the service.

The provider had effective systems and processes that shared important information with others. For example, people’s care and treatment needs were shared with external health care professionals, such as ambulance and hospital staff to support continuity of care.

External professionals confirmed there was a collaborative approach to care and treatment. For example, we were told how well staff shared important information about people’s care and treatment needs. This supported external health care professionals to make safe and responsive clinical decisions.

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 and relatives told us they had no concerns about safety. A person said, “I feel safe. Two times I fell, they [staff] helped me.” This person told us how they do not walk on their own now, and we observed staff helping the person and others to move around safely.

Staff had received ongoing safeguarding training and had access to the provider’s safeguarding policies and procedures. Staff were knowledgeable about the different types of abuse and their role and responsibilities in protecting people from avoidable harm and abuse. A staff member said, “We have to protect people from abuse and harm, if I had any concerns related to safeguarding I would report to the nurse or the manager, I feel confident that they would report on. I've not had to use the safeguarding policy yet but wouldn't hesitate to do so.”

The provider had made safeguarding information available in easy read and alterative languages for people using the service and information was also displayed for relatives and visitors. The registered manager was aware of the local multi-agency safeguarding policy and procedure. Records confirmed action had been taken when required in line with the policy.

A Deprivation of Liberty Safeguard (DoLS) authorisation enables a provider to place a restriction on a person lawfully. Where a DoLS authorisation had been granted with conditions, we saw how these were being met. The provider had systems and processes to monitor DoLS such as expiry dates and conditions and these were working well.

Meeting records confirmed regular discussions were had with staff about safeguarding and DoLS, this was to ensure staff were continually aware of people’s safety needs. The provider had relevant policies and procedures, that reflected current legislation and best practice guidance.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, whilst overall risks were managed safely, we identified some shortfalls that compromised people’s safety.

There was a positive approach to risk taking, and people were supported with their lifestyle choices. However, 1 person was supported to smoke and also used an emollient cream which was flammable, putting the person at increased risk. This risk had not been assessed or planned for. This was raised with the nurse in charge who advised this was an oversight and took immediate action.

Some people were at risk of choking and used a thickening powder for their drinks to support their swallowing. This powder is a significant risk if ingested directly and is required to be safely stored. However, we found a tub of this thickening agent in a person’s bedroom. Whilst the registered manager removed it directly and agreed to raise with staff, it had put people at potential harm.

People and relatives told us they were involved in discussions and decisions about how risks were managed. A relative said, “[Relation] has always been looked after well. I am informed if there are any changes or concerns, I feel involved in their care.”

People’s clinical risks and treatment needs were assessed and planned for and continually reviewed and monitored. People’s clinical care plans and risk assessments provided staff with guidance of how to safely care for people, and how to mitigate risks, were well detailed and up to date.

We observed staff supporting people to transfer using a hoist, this was completed safely and in a dignified manner.

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

Observations of the internal and external environment and premises found concerns in relation to safety. The premises was also found to be in need of redecoration and refurbishment.

For example, the external area had open access to the public, meaning there was a potential risk from unauthorised persons trying to gain access. This also compromised people’s privacy. The registered manager confirmed they had not completed a risk assessment to ensure all risks had been considered and planned for but agreed to do this.

The external pathways were uneven and a falls and safety hazard. Whilst the registered manager told us some floor slabs were due to be re-laid this would still not address all uneven pathways.

Some people smoked but had no access to a smoking shelter to protect them from the weather. There was limited outdoor seating for people and no sun protection, impacting on people’s comfort and opportunity to spend time outdoors. The large external garden was grassed with no flower beds to provide a pleasant, stimulating and visual experience for people. These examples show people’s safety and positive experience of the service were compromised.

The indoor environment was observed to be tired and worn with chipped and peeling paint on skirting boards and door frames. Walls in communal areas, including bedrooms, had visible stains. Communal bathrooms were generally untidy. We observed a broken bath panel, a specialised bath was not working and another was not used. We also observed a dirty and rusty shower chair. Pipes were exposed in 1 bathroom. We also found the top of people’s wardrobes were used for storage. These examples, show how people were at potential risk of harm.

Some concerns were identified with people’s bedroom furnishings that needed replacing and or repairing. Whilst we understood some people chose to have their own furniture, the safety issues we identified had not been fully addressed by the management team. We raised this with the registered manager who took some immediate actions to make improvements.

Some relatives raised concerns about their family member’s bedroom. A relative said, “The bedroom is not brilliant, it’s uninviting, shabby. It needs painting, and it lacks stimulation.”

The provider’s systems and processes that assessed and monitored the environment and premisses was not fully effective. At the time of the inspection, the registered manager told us they had a draft action plan for improvements to the environment. We were not sufficiently assured by this response. Following the inspection, the provider confirmed refurbishment, and redecoration had been added to their current improvement plan. The registered manager also completed some immediate actions to make improvements.

The provider had procedures to regularly check equipment were safe and fit for purpose. Fire safety and legionella testing (a water based bacteria that can cause significant harm) were regularly completed. External servicing on equipment such as fire safety, moving and handling equipment were up to date. We were aware there were ongoing improvements being made to fire safety. However, as recorded in the key question Well-led of this report, we were concerned of the length of time it was taking for these actions to be fully completed, impacting on people’s safety.

Score:

2

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Actions were being taken to improve the staff team in how they worked together to provide safe care that met people’s individual needs. However, further time was required for this to become fully embedded and improvements sustained.

Ongoing improvements were being made to staff communication, roles, responsibilities, expectations and accountability. We were aware there had been largely historic whistleblowing concerns raised by staff. Records confirmed these had been acted upon and investigated by the management team, who identified actions were required to improve the way the staff team worked. The management team had facilitated a number of team building meetings which meeting records confirmed, and this was ongoing. The management team, and staff, confirmed improvements had been made and this was ongoing.

The provider had a staff supervision and appraisal policy that stated staff should expect to receive an annual appraisal and 6 supervision meetings. These were important to support staff to discuss their work, training and development needs. Whilst staff were positive about the support they received, records showed, and the registered manager confirmed, staff supervisions were behind what was expected. The registered manager was in the process of arranging support with this task from senior nursing staff.

There were enough qualified, experienced and competent staff to meet people’s individual care and treatment needs. A dependency tool was used to determine staffing levels and this was reviewed regularly. One person had been assessed as requiring additional one to one staff support. Our observations, including care records and the staff rota, confirmed this was being provided.

People and relatives told us they were confident there were enough staff available at all times. Our observations confirmed this. Staff were available at all times in communal areas to monitor people’s safety and care needs and staff were not rushed when delivering care and treatment.

Staff were recruited in a safe way. Appropriate checks were carried out before employment was offered so that as far as possible, only suitable staff with the right skills and experience were employed. Nursing staff had their National Midwifery Council registration routinely checked, to ensure they were safe to practice.

The provider’s training matrix confirmed overall compliance was good. Nursing staff received clinical supervision and had their competency assessed in nursing tasks, to ensure they continued to practice safe care and treatment. Staff received training in a variety of topics the provider had identified as required and as we expected.

The provider had an infection prevention and control policy and procedures that reflected best practice guidance. Whilst the provider had systems and processes that assessed, managed and mitigated risks in relation to infection prevention and control practice, these were not sufficiently robust.

Observations of the environment found cleanliness and hygiene practice needed to improve. Whilst records confirmed domestic staff were provided with cleaning task guidance for both daily and deep cleaning, and cleaning schedules were up to date, the environment was not consistently clean and hygienic. This put people at greater risk of infections, impacting their health and wellbeing.

For example, we observed bathrooms were generally untidy and cleanliness and hygiene poor. A person’s mobile hoist sling was found on top of a clinical waste bin, increasing the risk of cross contamination.

We completed a sample check of people’s bed mattresses and found some examples of stained mattresses and protection covers, including stained bed linen and a lumpy pillow. Some people had crash mats by their bed for safety reasons. We found examples of these to be dirty.

We saw each bedroom had a monthly mattress check list that staff were expected to complete.

However, from our findings, we were not sufficiently assured these checks were being completed robustly. We showed the registered manager our findings who took some immediate actions.

The provider’s monitoring systems and processes included infection prevention and control. We noted the latest audit was described as a ‘mini infection and prevention and control audit’ completed in April 2025. The outcome was 100% compliant. Due to the level and widespread shortfalls identified during our inspection, we were not sufficiently assured the provider’s systems and processes that monitored infection prevention and control were robust. This put people at increased risk of harm.

The staff training matrix and feedback from staff confirmed they had received training in infection prevention and control. Whilst some staff told us they believed the environment to be clean, others raised concerns and told us it needed to improve.

We received a mixed response from people and relatives about the environment being clean and hygienic. Whilst some told us improvements were required, others told us they had no concerns.

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. However, we identified some areas of medicines management that needed improving.

Medicines were managed safely. We saw medicine administration record (MAR) charts were in place and had been completed accurately, showing people had received their medicines as prescribed. However, some people required their medicines to be administered covertly. This means being administered in a way the person receiving it, is not aware they are taking it. Whilst we saw letters the GP had completed authorising this, the pharmacist had not been consulted. This was recorded in the provider’s policy and protocol as being required. This is important to ensure the safe and effective administration of medicine. We discussed this with the senior nurse and registered manager who agreed to contact the pharmacist.

Mental capacity assessments and best interest decisions for people who lacked capacity to consent to medication were not in place. However, the registered manager was aware of this, and action was being taken to address this.

When people were prescribed medicines ‘as and when required’ (PRN), the correct PRN protocols were in place to guide staff on when to administer these medicines. Staff recorded when and why they had administered PRN medicines, and this information helped to inform people’s risk assessments and care plans.

Staff had received training in safe handling of medicines and their competencies were tested regularly. We observed a medicines round and saw medicines were administered in a safe way, However, we saw an example where a person’s dignity and respect was not maintained. This is recorded in the key question Caring of this report.

Medicines were ordered, stored and surplus stocks returned, following best practice guidance. Systems and processes including management oversight, were in place to continually review and monitor how medicines were being managed, and action was taken if medicines errors occurred. The GP or practice clinician visited the service weekly and completed annual medicine reviews or sooner if required.

People and relatives raised no concerns about how medicines were managed or administered.