Hyllden Heights 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.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

There were systems and processes in place for reporting incidents and accidents and when things go wrong. Staff knew about these systems and were confident to use them. One staff member told us, “If there was an incident like a fall or something else. I record it on the system and also let the unit leader or deputy manager know.” Records showed incidents were investigated and actions taken to ensure learning from them. When issues occurred within the service, they were discussed at daily handover, team meetings and head of departments meetings. They discussed actions to take and lessons from them. One relative told us, “My relative had a little fall and bumped their arm on the wall in the toilet, staff rang me and told what they have done about it. They have a policy on any fall or incident to follow.” People who had experienced a fall or were identified as being at risk were regularly monitored to ensure their safety and well-being.

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.

People and their relatives told us they had a positive experience of moving into the service. A relative said, “We visited the home a couple of times, and my loved one had lunch once during our visit. We wanted to experience what it was like before we decided. A senior staff sat with us to discuss [loved one’s] needs and they showed us around.” Staff liaised with services and professionals for their input so they understood the individual’s needs. This meant appropriate support and care could be developed to meet their needs. When people required aids or specialised equipment, arrangements were made to ensure these were in place upon their arrival.

Staff knew when to make referrals to specialist services to support them to manage people’s care safely. For example, we saw referrals made to physiotherapy team and tissue viability team to ensure people received safe care whilst in the home. Professionals we spoke with confirmed that staff took a proactive approach in making referrals and engaging with them to ensure individuals' needs were effectively met.

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 their relatives told us they felt safe in the home. A person commented, “I feel safe, it is nice and bright.” Staff had been trained in safeguarding and knew actions to take to protect people from abuse. A staff member told us, “Yes, I have had safeguarding training. If I suspected abuse I would report to the line managers and will document, it. The managers will then do the investigations. The home manager and deputy manager reports to the safeguarding team and CQC.”

The registered manager and deputy manager demonstrated a clear understanding of their duty to protect people from abuse. They adhered to established safeguarding protocols and responded appropriately to reported concerns. This included raising alerts with the local safeguarding authority, conducting thorough investigations, and informing the Care Quality Commission (CQC).

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 Act 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 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.

We found that people’s rights and freedom were promoted in the home. People moved around the home freely and could leave the home and return as they wished if. People had valid DoLS in place or a pending application with the local authority. The registered

manager understood their responsibility to promote people’s right and to notify CQC of any approved DoLS. Staff had been trained in MCA.

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 promoted their well-being.

Qualified and trained staff assessed the risks to people, there were risk assessments in place to identify risks associated with people’s physical health and mental health conditions, personal care, skin integrity, mobility, nutrition and moving and handling.

We reviewed risk management plans for people at risk of pressure sores, malnutrition, falls and behaviour that challenges and they contained relevant details to support staff to reduce harm to people and maintain people’s safety. Where people required specialist equipment to support them, this was provided. Risk assessments were reviewed regularly and updated to reflect people’s current situations.

Staff involved relevant healthcare professionals to support them in managing risks to people. We observed staff following safe moving and handling procedures.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home environment was well maintained and records showed health and safety checks were carried out regularly. These included electrical installation, gas safety, portable appliance test (PAT), and water management and legionella. The risk of fire was assessed and regularly fire system checks took place. Staff had been trained in fire safety.

Care equipment, including moving and handling aids, was regularly serviced, with maintenance records kept up to date. Each person had a personal emergency evacuation plan which highlighted their level of risk and support they required to evacuate the home in emergency situations.

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

A person told us, “Yes, I feel safe, I use my buzzer, and they are quite good coming quickly. It can be busy at breakfast time but on the whole, they are good at responding.” A

relative said, “My relative has been here for 3 years and it is a good place. There seems to be plenty of staff all the time.”

Staff were around and available to support people during mealtimes, with activities and in communal areas. We observed staff checking on people routinely in their rooms and offering support. There were qualified nursing staff available in the nursing unit throughout the day. Staff we spoke with commented they were enough to support people. A staff member told us, “I think we have enough staff as we are not always struggling to finish our task.”

Staffing levels were determined based on people’s needs and occupancy level which was reviewed daily to ensure the staffing levels continued to be safe and effective. We observed and the rota demonstrated home was adequately covered with a mix of qualified nurses and care staff.

Robust recruitment checks were conducted before applicants could work with people. These included criminal records checks, references, employment history and right to work in the UK. The provider also checked that nurses employed had the appropriate qualifications and their professional registration was up-to-date and continued to be valid.

Staff were supported in their roles through effective induction, support, supervision and appraisals. A staff member told us, “The company is very good at training. We had lots of training during induction and would need to complete this annually sometimes twice.” The registered nurses were supported to maintain and keep up-to-date with their professional development. The registered manager told us specialist training courses were booked for as when required to meet the needs of people.

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. A relative told us, “The toilets are always very clean.”

The home was clean throughout, and good standard of cleanliness and hygiene was promoted. The provider made personal protective equipment (PPE) available, and we saw staff using PPE effectively and safely.

The provider had an infection prevention and control policy that was up-to-date and covered measures to prevent and manage the outbreak of infections. Staff received training in infection prevention and control and were observed adhering to effective hygiene practices. Staff had activated their infection control procedure following a potential infection risk identified. They had set up a PPE station in front of the individual’s room and increased cleaning levels around the area.

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.

People’s medicines were administered and managed safely. A person told us, “I take tablets for blood pressure and heart condition. I’m always given on time and never missed them.” Only trained and competent staff were responsible for administering and managing people’s medicines. There was a medicine management policy and procedure in place. People’s care plans contained a list of their current medications and the details about the individual medicine and instructions for administering the medicines, for example, time sensitive medicines. Records reviewed showed staff followed the instructions as required. We also noted that ‘as when required’ medicines, were administered in line the protocol in place to manage them. Medicine administration records were maintained.

There were systems in place for managing controlled drugs (CD). CDs were securely locked in the medicine room. Regular medicines audits took place and CDs were checked daily. Medicines were stored within safe temperature.