Golden Horizon 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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 health and safety events. Lessons were learnt to continually identify and embed good practice. The provider took appropriate action to review any concerns to see if lessons could be learned. There was a shared learning tool following incidents/accidents suggesting when interventions needed to be implemented, such as enhanced post fall observations and preventative measures to prevent reoccurrence. Staff demonstrated skills and knowledge in keeping people safe. One staff member told us, “If a person had a fall I would raise the alarm with the emergency bell, wait for assistance, check the person over, if it was a major cut or break, I’d call 999. If they were on the floor, I’d use the hoist, inform the family and managers and do accident form and wound chart. I would take the person’s blood pressure, temperature and oxygen levels”.

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. Pre-admission assessments were completed prior to a person moving into the service to ensure their needs could be met. People had accessed healthcare when they needed it, and in the event of an emergency information was available about people’s needs and wishes. The provider shared some positive stories when they had helped people move into the service at short notice or return to the service when people had changed their mind about leaving. One external professional had shared their thanks, they said “Just wanted to say thank you for the support that you have recently offered to [person] at such short notice. Accepting this placement of care at short notice helped to ensure [persons] immediate safety”. The provider had agreed to an extended the persons stay until it was safe for the person to return home. The person told us they were extremely grateful for the prompt care and support they had received since they had been residing at the service.

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. All people and relatives we spoke with told us they felt safe living at Golden Horizon Care Home. One person told us, “I feel safe being here, they take safety very seriously”. A relative shared, “Definitely safe. There is someone around to help them if they need it”. Staff had received training in safeguarding and vulnerable adults and understood how to recognise concerns and what their roles and responsibilities were to ensure people were safe. Staff told us they felt confident with raising concerns and these would be responded to appropriately. One staff member told us, “If I had any concerns I would speak with the owners or the manager and I know they would take it very seriously”. Where people were being deprived of their liberty, referrals had been made to the local authority. The home manager monitored people’s Deprivation of Liberty Safeguards (DoLS) referrals by having a DoLS tracker to ensure people’s referrals were being submitted within the appropriate timescales.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things that mattered to them. People’s needs were assessed and formed part of their care plans. These included risks associated with the environment, mobility, medicines, skin care and eating and drinking. It had been identified some people’s needs had changed, and to reduce the risk of falls, the provider had offered some people rooms on the ground floor of the service. This enabled people to continue to mobilise independently but with more staff oversight. One relative shared, “My relative is mobile with a walker, but they do put it away when not using it as it is a trip hazard. They go to the lounge during the day and have an alarm mat by their bed at night”. Another relative shared “My relative had a fall, I was there. They sought medical attention. So, they then used to always stand behind them when they stood and walked but now, they go in a wheelchair. But staff do encourage them to stand on their own and gently put their hand on their back and gently guide them to the wheelchair”. We observed some people were able to walk around freely in the communal areas and to and from their bedrooms and bathrooms.

The provider had not always detected and controlled potential risks in the care environment. During our onsite visits we found some concerns which required improvements. Some areas of flooring throughout the downstairs of the building were uneven with metal joins which posed a risk people may trip or fall when walking independently. The provider had already identified this and had contacted an external provider to replace the flooring through the downstairs corridors to reduce the risk to people. This was completed shortly after our visits. We identified 2 windows in the downstairs hallway without window restrictors. These had been fitted by day 2 of the onsite inspection. We identified the staff bathroom door lock was broken, which housed a boiler which could be accessible to people, the lock was replaced by day 2 of the onsite inspection. The service environmental checks which had been completed had been carried out by both external contractors and internal staff to ensure the service was safe and had regular compliance checks. We asked a fire officer from Hereford and Worcester Fire and Rescue service to visit during our inspection process to review the building and staffing numbers at night. The fire officer identified staff had not received all of the required fire training to ensure they knew how to evacuate people safely in the event of an emergency. Prompt action was taken by the home manager and provider to ensure all staff participated in a simulated evacuation scenario and had their competencies checked. We also identified the service fire risk assessment was due to be reviewed, the provider took action to locate a suitable contractor to carry out a fire risk assessment review shortly after our onsite visits. People had personal emergency evacuation plans (PEEPs) in place which detailed what support was required. However, we identified not all people had been identified in the PEEP’S which meant in the event of a fire, there may be some confusion with how many people were required to be evacuated. We shared our feedback with the home manager and provider who updated the PEEP file and implemented a new audit document to ensure PEEPS were reviewed each time a person was admitted or left the service, along with a regular weekly check. The provider took prompt actions on all of our findings which reassured us people were safe.

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. It had been identified during the inspection process staff required additional fire evacuation training; this had been actioned. The majority of people, relatives and staff felt there were enough staff to meet people’s needs. One relative shared “There certainly are enough staff. They all know what they are doing. They are very good when they move them using that special lifting chair. There is always two of them. They have these little pads where they write everything down so people know what has been done. They always know what they are doing. They seem very competent” Another relative said, “They take in people to train. They keep their staff fully trained. If someone doesn't know something they say they will go and ask someone”. However, a staff member shared they felt staffing numbers could be increased and a family member said they felt there wasn’t enough staff on shift. During our visits, we did not observe people were waiting for long periods of time and call bells were answered appropriately. Staff were recruited safely and pre-employment checks were carried out to ensure members of staff were safe to work with vulnerable people. These included references and Disclosure and Barring Service checks (DBS). A DBS is a criminal record check to ensure the staff member is of good character to work with people at the service. Staff had received online and face to face training to ensure they had the knowledge and skills to support people safely and effectively.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service had domestic staff each day to ensure daily cleaning routines were in place. However, throughout the home we identified wear and tear to skirting boards, walls, doors and door frames, which may make it difficult to ensure areas of cleanliness are maintained effectively. The provider told us and records confirmed this was an action to be completed gradually in their service improvement plan. We observed staff wearing the appropriate personal protective equipment (PPE) when required. Staff had received the appropriate training in infection prevention and the manager liaised with the relevant authorities to ensure they were kept informed of any local infection outbreaks. Relatives told us they had no concerns with infection prevention, one relative said, “No issues with cleanliness. I have even popped my head around into the kitchen. I've seen lots of cleaning going on. No smells either”.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. There were systems and processes in place to support safe storage, administration and disposal of medicines. Staff had received the appropriate training and had their competencies checked and reviewed. The provider had a medicines policy in place for staff to refer to. Some people had ‘As and when’ required medicines in place, staff had documented why these medicines were required to ensure they had oversight of any changes, or concerns which would need escalating to the relevant medical professionals. Relatives told us they were satisfied with how medicines were managed at the service. One relative told us, “They come round with tiny pots and give their medicine. They all write it on their schedule, so everyone knows. They have had to change their medication but that is their job. They know what they are doing and they would tell me”. The service had a pharmacy visit during the inspection process to review their processes and documentation.