Signature at Hendon Hall

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 rating of this newly registered service. We rated this key question good. This meant people were safe and protected from avoidable harm.
 

This service scored 69 (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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were established processes to learn from mistakes and incidents. Reflective practice took place routinely amongst the staff teams and incidents were reviewed to prevent them happening again.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety effectively.

Nursing staff and leaders reviewed people’s health regularly and recorded the actions they had taken when a person was unwell, if their health conditions had changed, if they started to struggle to eat and if they entered the home with a wound to their skin. Staff followed the incident process of reporting if someone fell, obtained an injury, or became distressed. However, we found there were not safe established processes to ensure people who were at risk of choking, had received the correct food. We also identified a person’s pressure mattress was not set to the correct setting. No one had come to harm, but further work was required to improve these systems and create new ones. The registered manager, provider, and clinical lead took actions to correct these issues and improve systems during the assessment. They introduced further management checks about these issues.

The provider worked with people 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. The provider shared concerns quickly and appropriately.

When the registered manager identified potential harm, they made the correct referrals to the local authority. Staff were knowledgeable about what to do if they had concerns about potential abuse. They were clear they would report this quickly to leaders. They were also aware of the outside agencies they could report concerns to. For people who lacked capacity and had been placed under a deprivation of liberty order to keep them safe, these were being adhered to. We found these who lacked capacity were not being unlawfully restricted. Staff promoted their freedom to move about the home and to leave the home.

The provider did not always work well with people to understand and manage risks. This impacted on how effective staff could be to provide care to meet people’s needs that was safe.

People had risk assessments in place which identified the risks which people faced. However, some risks were not explored sufficiently with the appropriate plans in place to manage these risks. We found this with a person’s risk assessment who had oxygen prescribed as a medicine. Those at risk of pressure skin damage did not have effective risk assessments and plans in relation to the equipment used to help manage this risk. A decision was made to change the professional’s recommendation of a person’s assessed diet, without assessing the risk. Further work was needed to address these shortfalls, which the registered manager said would happen. They later came back to us and told us what they had done to address these issues.

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

Frequent checks were carried out to ensure the environment was safe to live in. A yearly fire risk assessment was commissioned by the provider to assess the fire safety of the building. Any recommendations were quickly adopted. Staff completed other monthly checks on the equipment used in the home to ensure the equipment was working and safe to use.

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

There was enough staff to meet people’s health and well-being needs. Staff had time to check people were ok, if they looked lost, upset, or were sitting alone. Staff intervened quickly when someone indicated they needed help with something. Staff spoke well of the supervision and training provided. Staff received training relevant to the people they supported. As one person’s relative told us, “On staff they [management] make good choices, in the dementia part of the home I have not seen agency staff for ages.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

The home looked and smelt clean. Any malodours were quickly addressed. The environment was well maintained to promote the work of the domestic staff. Food in the kitchenettes was stored safely. Staff followed safe hygiene practices when assisting people. The provider audited this aspect of the care provided.

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 received their medicines as prescribed. We completed a check on people’s medicines and found these people had received their medicines correctly. Staff spent time with people who were living with dementia to help them understand why they needed to have their medicines. When an error had occurred in the past this was quickly identified and actions were taken to try and prevent this from happening again.