Houndswood House 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 inspection, when the service was run by the previous provider, we rated this key question good. At this first assessment under the new provider the rating for this key question has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to medicines management, managing risk, safeguarding people from harm and staffing.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider lacked openness and transparency when incidents occurred. Staff told us they had raised safety concerns, but these were not addressed, and we found some notifiable incidents were not reported to CQC, as required. We queried this and found emphasis was on holding staff to account rather than identify actions and share learning with staff.

People did not feel safe. When they reported incidents, action was not taken to reduce the risk of reoccurrence. For example, a person told us staff had been rough when providing personal care. They told management, but nothing was done.

When concerns were identified by external professionals, action to address these was exceptionally slow. For example, concerns identified about medicines management at our first site visit on 25 February 2025 had still not been addressed when we returned for our third visit on 8 April 2025.

The provider did not work well with people and health system partners to establish and maintain safe systems of care and there was a lack of continuity of care. Information was not always sought in relation to people’s care needs or acted upon when advice was provided. For example,1 person did not receive their medicine as prescribed by an external health professional. A discrepancy in the prescription resulting in the pharmacy being unable to dispense the medicine was not followed up effectively. This meant the person did not have access to this medicine for over 3 weeks.

People’s records did not always have clear guidance from other professionals. For example, where people had modified fluids, this was assessed as necessary or reviewed by a Speech and Language Therapist (SALT). Records showed some people were given the incorrect consistency fluids. This could put people at risk of choking.

However, we saw the home was regularly supported by a GP who visited the home weekly and referrals were made to the district nurses as required.

People were not safe. The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider and staff at all levels did not have good understanding of their responsibilities to recognise and report safeguarding concerns. For example, there were known practice issues resulting in unsafe care being provided to people. There was a failure to take timely action or to report concerns in an open and transparent way to external bodies such as CQC and the local authority safeguarding team. We raised 7 safeguarding concerns during our assessment which had not been reported by the provider. These included serious errors with medicines affecting multiple people and a person who continued to be supported by a staff member they had reported as unkind.

The provider did not manage risk to people well. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People’s care plans and risk assessments had gaps and inconsistent information. For example, people did not have anti-coagulant risk assessments. People on anti-coagulants can be at risk of excessive bleeding if they are injured or if they have a fall. The deputy manager confirmed this but said that for all falls 111 or 999 was contacted. However, records did not provide evidence this was done consistently.

One person who had 2 medical conditions requiring conflicting treatments had no risk assessment to guide staff how to monitor symptoms of either condition. Records showed times where the person had consumed a very high fluid intake which could improve one of the conditions but negatively impact the other. Staff we spoke with about this could not confirm the records were accurate, and 1 staff member suggested it was likely their colleagues had not read the care plans.

Another person required their fluid intake to be monitored closely. Records showed multiple occasions when their fluid intake had been significantly below their assessed requirements. This put the person at serious risk of harm.

Staff completed fire drills and consistently identified the same issues such as taking too long to evacuate the building. They escalated this to managers and were told to do more drills. However, repeated issues indicated staff needed more training to understand their responsibilities in relation to evacuation. This put people at risk of not being safely supported to evacuate in the event of a fire.

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.

Staff completed various health and safety audits. However, checks including fire safety checks and legionella testing, were not completed for a month when the staff responsible was on annual leave. This put people at risk of harm if there was a fire because equipment had not been checked to ensure it was functioning correctly.

Staff were not able to document people’s care in a timely way. This was due to problems with network connectivity and had an impact on the reliability of records. For example, time critical records such as repositioning charts or certain medicines could not be verified as accurate because staff could not always document care at the time it was delivered.

After the assessment the provider told us the issue was more about staff having the correct log on details or going into rooms where there was less connectivity. However, this was several weeks after this was first identified and problems had continued during this time.

The premises were well maintained and decorated to a high standard. However there had been limited consideration of the needs of people living with dementia and little to support people to find their way around the building. Busy patterned wallpaper and flooring could increase the risk of overstimulation for some people, Patterned flooring can increase the risk of falls for people with perception difficulties who may see the patterns as holes or changes in the level of the floor.

The provider did not make sure there were enough qualified and skilled staff to meet people’s needs safely. They did not make sure staff received effective support, supervision and development.

People we spoke with said staff were always busy and did not have time to chat. Some people, particularly those staying in their rooms, said they felt lonely. A person said, “We verbally help one another – there is often no one in the room.” Another person said, “They don't have enough staff. [Some people] need 2 staff to look after them, the rest of us have to wait for the carer to come. If I call the bell eventually someone comes.” Some people told us activities were cancelled because staff were required to cover other tasks. We observed this during our site visits. We saw staff were not visible throughout the home both in communal areas and on floors where people were cared for in bed. Following our assessment the provider confirmed they intended to increase staffing to address these concerns.

Staff had not had sufficient training to meet people’s needs. This included Parkinson’s disease, Multiple Sclerosis, and various mental health conditions. Staff had also not completed training in supporting people with a learning disability or autistic people which is a mandatory requirement.

The provider had not ensured staff were competent in their roles. Medicines administration competency checks had not been completed in sufficient detail to demonstrate competency. There were no competency assessments for other clinical skills and some nurses had not yet received the appropriate training in skills such as recognising the signs of deterioration, use of syringe drivers or catheter care. We were therefore not assured people would receive safe care from suitably skilled staff.

The acting manager said they were developing training and competencies in clinical skills for nurses.

The provider assessed and managed the risk of infection. They detected and controlled the risk of infection spreading. The service was visibly clean, and we saw staff wore Personal Protective Equipment (PPE) appropriately.

Medicines management was unsafe at this service. The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People told us they were concerned about the support they received with medicines. A person said, ”Sometimes it is not regular – It depends who is on.” Another person said, “It’s my medicines I worry about”. We had widespread concerns in relation to medicines systems and processes, recording practice and administration. Staff used an electronic monitoring system, but a lack of training and problems with network connectivity led to many errors. They reverted to paper documentation, but errors continued. We identified multiple occasions where people had either not received their medicines as prescribed or had received too much medicine. Where people had ‘as required’ medicines, there were no protocols to ensure staff understood when it was appropriate to administer them. Medicines unsuitable for crushing had been crushed putting people at risk of harm. Changes in people’s medicines were not acted on and we found issues such as medicines which had not been booked onto the records system, a prescription unfilled for 3 weeks and medicine prescribed in one form being administered in another, such as tablets instead of liquid. These issues put people at serious risk of harm because we could not be assured they received their medicines safely.

After the third site visit on 08 April 2025 where we found the risk of harm to people remained, we took urgent action to require the provider to take immediate steps to address these concerns.