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 assessment we rated this key question inadequate. At this assessment the rating has changed to 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.

This service scored 44 (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 improved their culture of safety, to be based on openness and honesty. They identified and shared lessons learnt. Whilst some themes from incidents remained, such as moving and handling injuries, these continued to be shared, and action was being taken to address them.

The registered manager had encouraged staff to be open and honest when incidents occurred, and processes had been developed to improve shared learning. The registered manager said, “All incidents and accidents are analysed as it happens and discussed in weekly governance. The monthly audits collaborate all incidents and accidents, relevant safeguarding, CQC notifications, hospitalisation etc. Since we started the huddle in July a live document is maintained to log the lessons learnt.”

Staff completed incident forms and informed the nurse in charge who recorded action taken. The registered manager reviewed these and followed up any other action required. This included submitting notifications to CQC, where required.

People’s relatives were informed when incidents occurred and told us they were happy with how they were managed. A relative said, “There have been 2 incidents, 1 with an injury involving a hoist and 1 with medication… I was informed immediately and informed of actions taken to ensure it would not happen again.” Another relative told us, “When there was a medicine mishap, they rang me straight away and explained what happened.”

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.

Staff referred people to other services as required. The registered manager told us, “Referrals are being done much quicker, to get the district nurse for skin tears etc. Took time, but now they have the hang of it. They notice if someone is coughing, struggling with tablets, they tend to report it. Had Speech and Language Therapist (SALT) in recently.”

The provider attended Multi-disciplinary Team (MDT) meetings to discuss people’s needs and support them to access other services.

The provider was in breach of regulation regarding safeguarding at our last assessment. This was due to a lack of understanding of their responsibilities to recognise and report safeguarding concerns. At this assessment, we found this had improved, and the provider was no longer in breach of this regulation.

Staff reported safeguarding concerns, and these were shared with the local authority and CQC as required. The registered manager had a tracker to monitor safeguarding referrals. This included a very brief description of what happened and the outcome.

Staff were trained in safeguarding, and information was displayed on noticeboards. A staff member said, “People generally receive safe and good quality care. We have systems in place for reporting incidents and safeguarding concerns, and staff work together to maintain residents’ wellbeing.”

People and their relatives confirmed they felt safe at the service. A person told us, “I have been here a long time and feel safe.” A relative said, “We think [person] is being looked after, and we are happy that [person is] safe.”

Whilst the reporting of safeguarding concerns was an improvement, the number being raised was an issue. However, we saw the number of referrals per month was reducing. Medicine errors remained a theme and there had been some moving and handling related injuries. The registered manager told us moving and handling refresher training had been arranged for all staff in response to this and there were numerous actions ongoing to improve medicines errors.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last assessment, the provider was in breach of regulation relating to risk management. At this assessment we found some improvement, but the provider remained in breach of regulation.

Staff did not always follow guidance in people’s care plans and risk assessments. People’s care plans and risk assessments included guidance for staff to support them, but we found this was not always done despite additional steps implemented to mitigate this.

People’s monitoring charts were not always completed as required. This included for fluid intake to ensure they remained hydrated and re-positioning to prevent pressure injuries. During our visit we noted people were not on track to meet their daily fluid intake targets. We reviewed people’s records and found a person had not met their target for 6 days out of 14 and on 1 day no fluid recorded between lunch time 1 day and lunch time the next. “We observed a person who had not moved from their chair during our visit. Staff were unaware they had redness to their skin and had not ensured they were supported to reposition.” and when we reviewed their repositioning chart found this was not always done Another person was meant to be supported to reposition every 4 hours. This was not always done, and they developed a pressure injury. Staff noted for their repositioning to be increased to 2 hours, but we found this still was not documented as required. Therefore, we were not assured the provider’s processes to monitor risks to people were effective.

Staff did not always support people to maintain their oral hygiene. People had oral care plans in their records, but we found toothbrushes appeared unused. Prior to our visit a person had an unexplained missing tooth; it is possible this was a result of lack of support with oral care. We fed this back to the registered manager, and they identified an oral hygiene audit to be implemented as well as a training presentation they would deliver to staff.

People’s relatives did not have any concerns about management of risk. A relative told us, “The staff appear to be friendly, caring and knowledgeable in all aspects of care.” Another relative said, “All of the people who look after my [relative] seem very capable and well trained.”

The provider did not manage potential risks in the care environment well.

The provider’s fire evacuation procedure was not robust. During our visit, we found details of the fire team for the shift had not all been completed. We reviewed fire drills, which were completed frequently, and found the outcomes were erratic in terms of staff competence. Despite additional training, some staff were still unable to work the fire panel and 1 outcome stated, “Staff still did not know the evacuation procedure despite numerous training and regular practising.” This meant we were concerned people remained at risk of not being safely supported to evacuate in the event of a fire.

The provider had not considered the needs of people with dementia with the décor of the building. At our last 2 inspections of this service, we have reported on the patterned wallpaper and flooring which could increase the risk of over stimulation for some people or increase the risk of falls for people with perception difficulties. The provider told us they had not found this to be an issue with anyone using the service, but we remained concerned of the potential impact for people whose needs could change.

The provider did not have a health and safety audit to monitor checks around the home. The registered manager told us, “Unfortunately, we do not have a health and safety audit being used. I work with the folders of maintenance staff and confirm [their] daily, weekly, and monthly allocations are completed.” We reviewed maintenance checks and found these were completed and actions taken as required.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People were not always supported by enough staff. Staff were observed to be task-focused with limited time for social interaction. People we spoke with told us there were not always enough staff to support them in a timely way. A person said, “We do need more staff at times. There are only 2 staff. Which means we have to wait. If I call, they will come and then go very quickly.” Another person told us, “There is enough staff generally, but at times it is busy. Like now there is no staff to be seen as they all have to go in different directions.” However, a relative said, “There does seem to be enough staff, and they often chat to my [relative] as well as carrying out the duties.”

The provider used a dependency tool to calculate staffing levels, but we could not confirm how individual needs were factored into calculations. We requested further information, and this was not provided, so we were not assured staffing levels met people’s needs.

The registered manager provided evidence of clinical training for nurses, including catheterisation, venepuncture, intramuscular injections and syringe driver awareness. Limited nursing care at the time meant competencies could not be formally assessed. However, people were supported with catheter care, and we noted competency assessments had not been completed for this. A nurse told us, “We have regular conversations with the clinical nurse about competencies. We are supported with revalidation activities, although this is on our own time. If I need support I would ask the clinical lead, registered manager or deputy.”

Staff received additional training and competency assessments when errors and incidents occurred, and most staff felt they had sufficient training for their roles. A staff member said, “I’ve received proper training and support to meet people’s needs effectively.” However, 1 staff member told us they were concerned about the effectiveness of the training given the incidents which continued to occur. They told us, “Watching a video and choosing A, B, C answers is not training.” Therefore, we remained concerned about competency among the staff team to ensure people were safe.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider submitted a notification to CQC 9 September 2025 to advise high levels of legionella had been found during routine water testing 16 August 2025. There were ongoing actions such as replacing all Thermostatic Mixing Valves (TMV.)

During our visit, we found 4 bedrooms had signs to advise enhanced barrier precautions with Personal Protective Equipment (PPE) outside. The bedroom doors were open; 1 person was not in their room and there was no waste disposal available. We observed staff did not always wear the PPE as required and when we asked staff where to dispose of our PPE we were told to put it in the bin inside the person’s room. Therefore, we were not assured staff understood the procedure.

We discussed this with the provider and were told there were only 2 people who required barrier nursing as a precaution due to respiratory symptoms; no one had tested legionella positive. The registered manager told us they had resourced legionella awareness training for staff.

The provider completed IPC audits. We reviewed this for September 2025 and found actions for policies to be updated as not tailored to the home had been required for a few months. The legionella risk assessment was dated 2021 and had not been updated despite the recent issue. However, the home was visibly clean throughout.

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.

We saw significant improvements in medicines management since the previous inspection. The service had employed a pharmacist to oversee the improvement of medicines optimisation and management.

We saw that medicines, including controlled drugs were being managed safely. We saw that people received their medicines for when they were prescribed, including medicines that were time dependent. Medicines, including controlled drugs were kept secure and access was only available to authorised staff. We saw that medicine related risk assessments had been updated to accurately reflect the risks and needs to people taking high risk medicines such as medicines used to thin the blood.
The service had recently moved from paper-based recording systems for recording administration to electronic systems. The service told us that the systems would be further simplified as part of their improvement process. When people were given their medicines covertly, these were administered and recorded in line with national guidance and legislation.

The service had positive relationships with other local healthcare professionals including the local GP and community pharmacy.

There was an effective process for recording and learning from medicine related incidents. We saw that learning was reviewed monthly and shared with staff via team meetings.

We saw that “when required” (PRN) medicines were managed safely. We saw clear protocols describing when and how to use the PRN medicines that were staff were able to use. These were kept in accessible areas for staff.

We saw people were supported to take their own medicines. We spoke with 1 person who told us that they were well supported in the service, and they spoke highly of the staff.

Staff received medicines related training to support them in their role. Their competency was assessed by the pharmacist. The service leaders told us they had completed workshops and training themselves to be able to safely assess the medicine related competencies of staff in the service.