Cross Heath Grove

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 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 regulations in relation to people’s safe care and treatment, the ways people’s medicines were managed safely and governance at the service.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had systems in place to support learning when things went wrong, but these were not always effective. Accidents, incidents and medication errors were recorded, and action was taken following individual events. However, there was limited evidence of robust analysis of trends or learning specific to the service to reduce the risk of recurrence. We found medication errors had continued despite incidents being reviewed, indicating learning was not always embedded into practice.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems for assessing, planning and delivering people's care were not always effective. We found examples where important information about people's health needs was not fully captured before respite stays, including inconsistencies relating to emergency epilepsy medication. Some care records lacked sufficient detail to guide staff and ensure consistent care. The provider worked with relatives and healthcare professionals in many areas, but improvements were required to ensure all relevant information was available, accurate and reviewed before people accessed the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

There were safeguarding policies and procedures in place and staff had completed safeguarding training. Staff demonstrated an understanding of safeguarding responsibilities and relatives told us people were safe. However, safeguarding systems were not always effective. We found a pattern of safeguarding concerns linked to medicines and unexplained bruising, but there was insufficient evidence of trend analysis to identify underlying causes and prevent recurrence. We also found statutory notifications had not always been submitted appropriately; we discussed these issues with the provider and action was taken to address them.

Deprivation of liberty safeguards (DoLS) applications had been submitted, when required.

The provider did not always manage risks to people safely. Risk assessments and care plans were not consistently detailed, accurate or reviewed in a timely way. We found examples where known risks, including choking risks or skin integrity concerns were not adequately assessed or reflected in care records.

Records relating to delegated healthcare tasks were not always sufficiently detailed and did not consistently demonstrate oversight from appropriately qualified healthcare professionals. This placed people at risk of receiving inconsistent care and support.

Some restrictions had been introduced, including monitoring devices used during the night, without clear evidence that decisions had been made in people's best interests or that less restrictive options had been considered. The provider took action to address these concerns.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found concerns relating to equipment governance. While hoists had received the required checks, the provider could not demonstrate that slings used to support people had received appropriate Lifting Operations and Lifting Equipment Regulations’ checks. Leaders responded positively to feedback and advised that additional checks and organisational review processes would be implemented to ensure equipment used by staff to move and lift people was safe to use.

During the assessment we identified areas of the home that were worn and required maintenance. There was a plan in place to work to address these issues.

The provider did not always 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.

There was a training plan in place, and several staff members had received training, and competency assessments were completed in some key areas. However, we also found examples of gaps in training in essential areas of care. Although the provider had recognised these gaps, staff had been booked onto the required training many months ahead. This affected leaders' ability to assure themselves that staff were appropriately skilled and supported to meet people's needs consistently and safely.

Recruitment processes were managed safely and most staff told us they felt supported by management.

Staffing levels were reviewed depending on people's needs and we found these 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 had arrangements in place to support infection prevention and control. However, we identified areas where practice required improvement. We found food items were not always appropriately dated when opened, creating a risk that stock rotation and storage arrangements were not always fully effective and placed a risk to people. Leaders responded to concerns raised and advised that staff’s practice would be reviewed.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not always managed safely. Our findings raised concerns about medicines management, including inaccuracies in documentation and practices that placed people at risk of harm. For example, a person’s care plan indicated they required emergency medication however at the time of their stay this was not available at the service. We also found a lack of person-centred protocols for medicines administered ‘as and when required’ and inconsistencies between prescribing information and administration practices.

Auditing systems had not been effective in identifying or addressing these issues before the inspection, despite evidence of medication-related incidents and safeguarding concerns. The provider took action or told us the action they would take to improve this area.