Heywoods Grange

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 good. At this assessment the rating 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, risk management, and environmental safety.
 

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. Risks identified during inspection were acted upon when brought to staff attention; however, provider systems had not always identified these concerns beforehand. We found gaps in oversight relating to medicines, environmental risks, Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) processes and staff records. While leaders acted during the inspection to address several concerns, systems for recording near misses, analysing incidents and embedding learning were underdeveloped.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Staff knew people well and sought support from health professionals when concerns arose. However, records showed referrals, specialist recommendations and communications with external agencies were not always followed up or documented consistently. People did not have regular reviews, and we could not see a system in place to ensure this was happening. This limited the provider's ability to demonstrate effective oversight of people's care pathways and continuity of support when needs changed.

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. Staff understood the importance of protecting people from harm; however, records did not consistently demonstrate that concerns and behavioural incidents were recorded correctly, assessed for safeguarding implications or escalated appropriately. CCTV cameras were seen within communal areas, but consent arrangements and governance documentation relating to its use were not fully evidenced. Safeguarding systems required strengthening to ensure concerns were identified, recorded and shared appropriately.

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. Risk assessments were generally in place, and we found examples of personalised risk management, including clear moving and handling guidance for one person. However, documentation did not consistently demonstrate how people had been involved in decisions about restrictions, support arrangements or managing everyday risks. Records also showed limited evidence of discussions with relatives and representatives to help ensure risk management arrangements reflected people's preferences and rights.

The provider did not 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. The provider did not identify and manage environmental risks effectively. We found several concerns relating to the physical environment, including an unused stair-lift within the stairwell, alterations to a fire exit and aspects of external access. Staff responded positively to feedback and demonstrated awareness of some risks; however, on our second visit, the risks that had been highlighted had not been mitigated, and records did not consistently evidence ongoing environmental monitoring or robust risk assessment processes. This limited the provider's ability to demonstrate that all potential hazards had been identified and managed appropriately.

The provider did not always make sure there were enough qualified, skilled and experiencedstaff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care thatmet people’s individual needs. Relatives consistently told us staff understood people's needs and routines, with one relative commenting, "They know [relative] really well." One person told us, “I like them [staff] because they take me for my activity.” However, the provider was unable to demonstrate a dependency-based approach to determining staffing levels. Staff’s supervision and appraisal arrangements were not consistently maintained, and regular competency assessments for staff administering medicines had not been completed. This limited assurance regarding ongoing staff development and competence.

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 had systems in place to support infection prevention and control; however, these were not always consistently monitored. We observed examples of good practice, including the secure storage of creams and personal items, and the environment appeared generally clean. However, pet-feeding arrangements within communal areas were not supported by documented cleaning schedules, limiting the provider's ability to demonstrate effective oversight of all potential infection risks. Opportunities remained to strengthen monitoring and assurance processes.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Staff had not received regular competency assessments, medicines audits were limited, and recording systems did not consistently document refusals, pro re nata medicines, (PRN) medicine outcomes, or medicine changes following clinical reviews. Some written guidance was inaccurate or lacked person-centred detail, and non-prescribed medicines had been administered without appropriate clinical oversight. Medicines were stored securely and at appropriate temperatures, and records showed people generally received their medicines as prescribed. However, oversight systems were underdeveloped. The provider acted during inspection to strengthen medicines governance, including introducing medicines incident reporting and disposal records.