Haresbrook Park 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 safe care and treatment.

This service scored 62 (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.

There was a system in place for staff to report incidents and accidents and staff were able to contact a manager through an on-call system for out of hours guidance. Relatives were kept informed of any accidents or incidents which occurred.

Accidents and incidents were routinely reviewed by the management team to identify trends and opportunities for improvement. Lessons learnt were shared with the staff team through daily handovers and during staff meetings.

Staff understood their responsibilities to record and report any accidents or incidents. We found improvements since our last inspection in décor of the service and improved premises. Following our inspection visit the provider told us any lessons learned would be shared with their team during a team meeting, and additional training had been booked for staff in areas of concerns highlighted during this inspection.

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.

The provider had processes in place to ensure relevant information was shared with other stakeholders and professionals when people were transferred to external services, such as hospitals. This included sharing key information about people’s needs to support safe and effective transitions.

The provider worked in partnership with the local GP and other healthcare professionals to support safe transitions between services. Systems were in place to support people when they returned from hospital, including reviewing care plans and updating risk assessments where required to reflect any changes in people’s needs.

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.

Staff had completed safeguarding training and understood how to report concerns about abuse or neglect. This included raising concerns within the service and, if needed, externally to relevant stakeholders. A staff member told us, “Any concerns I would report to seniors, if they do not take it seriously, we would report to the management of home. Then I would escalate it to external agencies.”

There were effective policies and procedures in place, and safeguarding concerns were reported appropriately and in a timely manner to relevant external agencies. Where there were concerns people had been subjected to abuse or neglect, the provider acted with integrity by reporting these incidents and worked in partnership with other organisations to ensure people were safeguarded from harm.

The provider did not always 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.

We found examples where risk assessments contained contradictory information which created potential risks to people’s safety. For example, 1 person had 2 different assessment tools to assess their skin integrity. According to 1 assessment tool the person was not at risk of developing pressure ulcer, however, according to another tool the person was at high risk. This posed a risk of staff not following appropriate risk assessment and putting the person at risk of their skin integrity being compromised. Some care plans required updating.

The provider took immediate action and following on-site visit provided us with a sample of updated care plans and risk assessments.

Some people’s relatives told us they did not feel included in care planning and pre-admission assessments. One person’s relative told us, “He had a care plan done in the past at a previous service. But I don’t know if it’s out of date. On transfer to Haresbrook no one has chatted about his needs.”

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

Systems were in place to make sure people lived in a safe environment. Compliance checks to ensure the safety of the building and environment were up to date. Equipment used to support people, such as hoists, were serviced and inspected in line with regulations. We saw equipment was appropriately maintained and clearly labelled.Fire alarms were tested weekly, and evacuation procedures were clearly documented. Fire safety equipment was in place and regularly checked. Water checks and water tests took place regularly to prevent growth of harmful bacteria.

However, some window restrictors were not compliant. This posed an environmental risk for people living with dementia. We raised this with the registered manager who reassured us they were going install different type of window restrictors.

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 recruitment checks were now all in place. This included obtaining Disclosure and Barring Service (DBS) checks. These provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

People and their relatives told us that staffing levels were recently increased and were adequate to people’s needs. One person told us, “I think there are enough carers. Usually, they are within half a minute or so.” A relative told us, “Recently more staff have come in. Now, I think there are enough. There’s enough on weekends.”

Staff told us there were enough of them to meet people’s needs. A member of staff said, “Mostly we have enough staff, unless someone is sick with a short notice.”

The provider did not always assess or manage the risk of infection. However, the provider shared concerns with appropriate agencies when required.

During our visit we found some areas of the kitchen dirty, and some food items without open dates. This posed a risk of food contamination and food spoilage.

Staff used Personal protective equipment (PPE) correctly and disposed of it safely, and people were offered hand wipes before meals. The provider had an IPC policy, and staff had completed IPC training.

The provider did not consistently ensure the safe management of medicines. Records related to medication management were not always accurate, and some signatures were missing.

We started our inspection in the morning and found that the medicines handover had already been signed off in advance for the afternoon. This posed a risk that any issues related to the management of medicines could be missed, and important information might not be effectively communicated to the next person responsible for managing the medicines.

Some signatures were missing in medicines handovers and controlled medicines checks. Medicines administered as required (PRN) protocols and controlled medicines where not transferred to electronic medicines administration record (Emar) system. As a result, staff were required to refer to both paper and electronic records when administering and monitoring medicines, which may increase the risk of administration errors and reduce the effectiveness of audit processes.

Staff’s competencies in administration of medicines were assessed by a deputy manager. The deputy manager has not received any additional training on how to assess staff’s competencies in this area.

We reported this to the leadership of the service, and they took immediate action in response to our concerns. Controlled medicines were added to Emar system. Following identification of the issue, a review of the medication auditing process has been undertaken to ensure that controlled drugs held within the home are routinely cross-referenced against Emar records, particularly following system changes or data migrations, to reduce the risk of a similar oversight occurring in the future. The registered provider told us they would arrange additional training for leaders responsible for assessing staff’s competencies in administration of medicines.