Lepton Heights Health Care Limited Also known as Exemplar Health Care

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.

Systems were in place to make sure learning was taken when something had gone wrong or when somebody had been at risk of harm. Accident and incident reports were detailed and included reflection of what had gone well or what could have been managed better. Information about and learning from accidents and incidents was shared with all staff through daily huddles, handovers and staff meetings and discussed during a 4 weekly business review meeting. Systems were also in place for shared learning between all of the provider’s services.

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.

Effective and robust systems were in place to make sure the service was right for people before they were offered a place. Pre-admission assessments were completed by the manager or clinical manager along with a member of the provider’s clinical assessment team who collated all the available information about the person to make sure an informed decision could be made about if the person could be supported safely at the service. The manager told us they were never pressed to accept somebody whose needs they did not feel confident could be met or, would not fit in well with the people already living there. The admission process was managed well with the person making visits to the service to get to know people and staff before moving in.

Staff always accompanied people on hospital visits and if admission was needed, conversations took place with the funding authority about staff continuing to provide support while the person was in hospital, particularly when the person received 1 to 1 support.

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 felt safe when using the service, and this was confirmed by their relatives. Safeguarding was a clear priority, with staff across all departments receiving training appropriate to their roles. The manager had created a ‘Safeguarding Wall’ in the reception area, which provided information about safeguarding, guidance on what to do if concerns arose, and useful contact details for people using the service, staff, and relatives.

Safeguarding issues were discussed at weekly regional managers meetings with the regional director for operations.

Where people were subject to Deprivation of Liberty safeguards (DoLS) the provider had made applications to the local authority and there was clear monitoring in place. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.

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.

People and their relatives were involved in the initial risk assessments, alongside relevant professionals supporting the individual. Risk assessments were reviewed two weeks after the person had started to live at the service, with a further comprehensive reassessment undertaken at six weeks by a clinical assessor. This ensured care and support continued to be delivered at an appropriate level and, where possible, identified opportunities to safely reduce levels of support.

Risk assessments were in place; however, senior staff had recognised that some required further development to ensure they were sufficiently detailed and robust. Work to strengthen and improve the quality of risk assessments was in progress.

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

Effective systems and processes were in place and consistently followed to ensure people lived in a safe environment. Robust fire safety and prevention policies were implemented and adhered to at all times. A health and safety committee was established, and clear information was displayed on notice boards to guide staff and people on how to raise health and safety concerns and how these concerns would be managed.

Technology was used to enhance safety, including a call system that required staff to swipe their card when responding. This allowed colleagues to identify who was first on the scene and understand the level of support required.

The manager outlined plans to dedicate one floor of the home to supporting people living with dementia. Proposed environmental and decorative changes would help individuals navigate the space more easily and safely.

Up-to-date critical incident reporting and business continuity policies were in place, further supporting the safety and management of the environment.

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.

Staff told us there were enough of them meet people’s needs safely. Staffing was organised in response to people’s needs.

Staff told us about the robust induction and training programmes they followed from starting work for the provider. New staff in all departments of the service were supported by a trained ‘induction buddy’ who were rewarded with a shopping voucher for their part in helping new staff become part of the team. In addition to the training programme, staff received training in relation to the individual and specific needs of people living at the service. Staff had access to further training such as leadership pathways and apprenticeships in care.

Agency use was being reduced through a system for letting staff know about overtime opportunities and ongoing recruitment.

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.

Infection prevention and control were managed well. Two staff champions completed audits, and an infection control board was in place to give people advice and information. One person told us, staff changed their gloves when they were assisting them with care and said, “They’re [staff] very good with that and it’s very important to me”.

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.

Medicines were stored, managed and administered safely. Protocols were in place for administration of medicines given on an ‘as required’ basis and where medicines were delivered through a skin patch, safe systems were in place to make sure the site of the patch was rotated.

Safe and appropriate processes were followed for when people needed to have their medicine given covertly [hidden in their food]. Topical medicines such as creams and lotions were managed safely.