Haywood Oaks 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 people’s safe care and treatment and the ways people’s medicines were managed.

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 did not consistently demonstrate a proactive or positive learning culture to support safety and continuous improvement. Systems for reviewing incidents and implementing learning were not embedded or effectively used to drive service improvement.

While incidents were recorded, there was limited evidence that investigations were followed by appropriate managerial review or clear action plans. Actions identified were not consistently tracked or reviewed to ensure completion, and there was no assurance that lessons learned were evaluated for effectiveness. There was no evidence to show learning from incidents was routinely shared with staff, meaning opportunities to reduce the risk of recurrence and improve practice were missed.

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.

Care plans contained details of external professional’s recommendations. Where people required support with routine health care appointments for conditions they were living with, such as diabetes and general healthcare screening, these were clearly identified in care plans and review dates were monitored to ensure people received their care and support safely and responsively.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. 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 while MCA and DoL’s had been completed and or applied for whether appropriate, the poor quality of daily recording of care actions meant we could not be assured people were supported in line with needs safety or consistently. This placed people at ongoing risk of harm.

The registered manager did inform external agencies such as the local authority and CQC when concerns had been identified as required.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that met people’s needs in a safe, supportive way that enabled people to do the things that mattered to them. Important information was missing from some care plans, which meant staff lacked clear guidance about how to deliver safe and consistent care. For example, care plans did not always contain instructions on how staff should appropriately support people with catheter care or repositioning needs. This created a risk of inconsistent practice and meant people were not always supported in a way that protected their safety and promoted their independence.

The provider did not always detect and control potential risks within the care environment, and equipment and facilities did not consistently support the delivery of safe care. During the assessment, environmental hazards were identified that had not been addressed. For example, metal grills on convection heaters throughout the home became excessively hot and posed a scalding risk. In addition, items were stored on top of some wardrobes in people’s bedrooms, creating a risk of objects falling and causing harm. These issues showed that environmental safety checks and risk mitigation measures required improvement.

The provider responded to this feedback and took step to address these risks immediately.

While the provider ensured there were enough trained staff on duty, oversight and support systems had failed to identify inconsistent and, at times, inaccurate record‑keeping. This meant opportunities to support staff to improve their practice had been missed, placing people at risk of receiving unsafe or poorly evidenced care. Concerns were also identified within recruitment records. For example, one staff member’s employment history contained unexplained gaps, and there was no system or policy in place for Disclosure and Barring Service (DBS) checks to be reviewed for staff currently employed. A DBS check is record of an individual's criminal convictions and cautions used by employers in England and Wales to make safer hiring decisions. These gaps indicated that recruitment and ongoing staff oversight processes were not always robust or aligned with safe practice to ensure staff recruited were and remained suitable to work vulnerable people.

The provider did not always assess or manage the risk of infection effectively. Although communal areas of the home were cleaned and maintained, some areas required further attention. For example, the cupboards under sinks in people’s bedrooms were dirty, indicating they had not been included within regular cleaning routines. In addition, care items such as continence products and catheter equipment were stored in open packaging, increasing the risk of contamination. These issues showed that infection control m easures were not consistently applied throughout the service.

The provider did not always make sure medicines and treatments were safe or aligned with people’s needs, capacities and preferences. Staff did not always involve people in planning their medicines support, and several practice concerns were identified. Expired medicines were found in both use and storage, and medicines awaiting return were not logged or stored appropriately, increasing the risk of administration errors. Staff also failed to complete Medicine Administration Records (MAR) for topical medicines such as creams, meaning the provider could not demonstrate these medicines were administered as prescribed. This indicated that oversight of medicines management required improvement. Where people required as needed medicines there was clear guidance for staff on how and when to administer these medicines. People received time specific medicines in line with prescribed times.