Higher Park Lodge

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. This key question 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 regulations in relation to premises and equipment, safe care and treatment, maintaining peoples care records, staffing and recruitment.

This service scored 50 (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 from to continually identify and embed good practice.

Incidents and accidents had been recorded, but learning from these had not been recorded. As noted elsewhere in this report, there was no audit system in operation for care delivery and so multiple failures in the direction and delivery of care had not been identified. For example, some peoples’ weight was not being assessed, where their weight assessment was needed to inform the safe setting of their skin tissue pressure relieving mattress.

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 service worked with external professionals to support people.For example, the GP practice that supported the home spoke with the service managers weekly, to review anyone whose health was causing concern to the service.

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.

The service had a safeguarding policy and procedures. Staff we spoke with were confident they could recognise and raise any potential safeguarding issues. However, some elements of the service were of poor quality as recorded elsewhere in the report, putting some people at risk of harm.

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.

People’s individual risk assessments had not been kept up to date and accurate to record changes to people’s risks and how these were being managed. For example, one person had previously had bedrails. However, these bedrails had been removed and replaced by a crash mat. These changes had not been recorded in either the person’s risk assessments or care plan and this person’s risk assessment and care plan still said the original bedrails were in place.

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.

When we visited the service there were many failures in the building’s environment, including cleanliness, furnishings, and equipment.

There was a strong smell of urine throughout the home and more strongly in some individual bedrooms. When we visited again 3 days later this had improved but was still present.

On our first visit the service was dirty in places, cluttered, and with damaged and broken furnishings. For example, the hallway and stair carpets were all heavily stained, worn and dirty. Chairs used by people in their bedrooms and in communal rooms were dirty, stained and damaged.

Window openings on some windows were not restricted in line with best practise guidance. This placed some people at risk of a fall from height.

Fire protection measures had not been adequately maintained to keep people safe. For example, self-closing fire doors were being inappropriately wedged open using household items.

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 well to provide safe care that met people’s individual needs.

When we first visited the service, there was no staffing level assessment tool in use to identify the necessary level of staffing to meet people’s needs. The availability of staff providing care and how they were organised meant, particularly at times when most personal care was being given, there were not enough staff providing care. When we returned to the service 3 days later the Registered Manager had developed and used an appropriate staffing level assessment tool, which showed an increase in care hours was needed. Care staff hours were being increased during our assessment based on our feedback.

Care staff were not being adequately trained. The training matrix recorded 64% of staff members had completed their required training, and no records were made available to show new staff members had completed their induction training.

We were told the services policy was to hold individual supervision or appraisal meetings for all care staff every 6 months. No records of when supervision meetings had taken place were made available. Staff supervision sessions were not taking place at this frequency. For example, one staff member told us their last supervision was in October 2024. This was 8 months ago and so did not meet the service’s supervision frequency policy.

Staff had not been recruited safely. For example, there were no records of references being taken for several newly recruited staff, and their employment histories were incomplete. We were told by the Registered Manager that staff had interviews before starting work with the home; however, no record of these meetings taking place was made available.

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

When we first visited the service the kitchen facilities were dirty. For example, there was food debris on the floor and surfaces including the cooker hob were dirty. Inside the fridge was dirty and both waste bins were full. Restriction of possible cross infection was not being promoted in the kitchen. For example, no hand towels were available at the hand washing sink for staff to dry their hands. No cleaning schedules were present for the kitchen, and the Registered Manager could not say what the cleaning schedule was.

When we returned 3 days later, we saw a deep clean of the kitchen was being carried out by an external cleaning contractor.

When we first visited the home, bathrooms and toilets were dirty. For example, 3 toilets and a commode had dried faeces on the seats and bowls. Soiled clothing and linen had been dropped and left on people’s bedroom floors. When we returned to the home 3 days later, the cleanliness of the home had much improved and new cleaning schedules had been organised.

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

Medicines were being stored and disposed of safely, people were supported to take their medicines as prescribed and staff had the appropriate training and competency testing for them to administer medicine safely.

When we first visited the home the surfaces and floor in the medication room were littered with debris, and inside the medication fridge was dirty.When we returned 3 days later the room and inside the fridge had been cleaned.

On our second visit the temperature in the medication room was recorded by the service’s thermometer as 28 degrees Centigrade. Therefore, the medication room was too hot for medications to be stored safely at room temperature.