Harper house - Wolverhampton

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 the service under this provider. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 38 (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. Lessons were not always learnt to continually identify and embed good practice.

Staff gave mixed feedback about the safety culture of the service. For example, 1 staff member told us, “They pick me up on petty things but aren’t dealing with the big things.” Another staff member spoke more positively, saying, “If there was an incident or accident, I would seek medical attention if I needed to. I would document and report this to management and carry out first aid.”

The systems in place to manage safety incidents in a consistent and effective manner were not always effective. We reviewed 3 incident forms and found there was an inconsistent approach to learning from incidents as only 1 of the incidents had effective action in terms of lessons learned. The lessons learned section of 1 completed form was blank which meant the opportunity to learn from the incident had been missed and the risk of further incidents occurring remained high. Another incident form contained reference to some lessons learned. However, on the day of the inspection, we saw the learning from the incident was not put into practice by the staff, leaving people at risk of harm.

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

People did not always have detailed or up to date care plans or risk assessments in place. For example, detailed care plans were not in place when people required modified diets to guide staff in how to provide safe and consistent care. This placed people at risk of receiving unsafe and/or unsuitable care.

Effective systems were not in place to ensure the care people received, including the diets people received, were monitored to ensure they were safe and met their needs. This meant people continued to be exposed to the risk of avoidable harm as safe systems were not in place.

However, the provider told us a system was in place to ensure people’s needs were assessed prior to their admission to the service, and these assessments were used to create care plans for staff to follow. Staff we spoke with confirmed this.

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.

People and their relatives gave mixed feedback about safety. For example, 1 person described the staff as, “Bullies”. Another person implied they felt safe as they told us, “I love it here.” Feedback from relatives was also mixed. Comments from relatives included, “I have had my [relative] ring me a few times and I have heard staff in the background being really rude towards them” and, “[Person] is happy with the staff that care for them. I have no concerns regarding the staff. They never speak out of turn to anybody.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. DoLS information staff gave us did not match the information the provider shared with us detailing which people had DoLS in place. For example, 3 staff members told us a person had a DoLS in place to prevent them from leaving the service unsupervised. However, this person did not have a DoLS in place to lawfully prevent them from leaving the service unsupervised. This meant we could not be assured that people’s right to live free from unlawful restrictions was not consistently protected.

However, staff had completed safeguarding training and staff were able to describe potential signs of abuse and how they would escalate this. One staff member said, “Safeguarding is to protect people. I look for signs of abuse, such as bruising. I would report any concerns straight away. I have had online safeguarding training.”

The provider did not work well with people to understand and manage risks. Staff did not consistently provide care to meet people’s needs that was safe.

Where it had been identified that people were at risk of choking, the provider had not taken action to keep them safe. There were no detailed care plans or risk assessments in place that identified what foods were safe for these people to eat and staff were unable to accurately inform us who required modified diets and what these diets should consist of. Care records showed people who required modified diets to minimise their risk of choking regularly received food that was not in line with their needs and professional recommendations. This placed people at risk of choking.

People had plans in place to minimise the risk of harm as a result of distressed behaviours. However, we found these plans were not always followed. For example, on the day of our inspection we saw a person was given medicine in response to a distressed behaviour. This medicine was given before the recommended actions in the care plan were followed which meant the medicine which had a sedative effect was given as a primary response to the behaviour rather than as a last resort.

However, people raised no concerns with how their risks were managed. We found some examples of some appropriate risk assessments that were in place for people.

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

The provider was renovating the property. However, no effective risk assessment was in place to reduce the risk of harm as a result of the building work. Communal areas were cluttered with tools, which included a saw, contractors equipment, and building work debris, presenting significant trip hazards. Staff confirmed the renovation works resulted in an unsafe environment. Comments from staff included, “I would say the environment is not safe at the moment. Due to the workmen leaving equipment about” and, “At the moment yes it is unsafe, but that’s due to renovations.”

Effective systems were not in place to ensure people were protected from the risks associated with hot water and hot surfaces. For example, records showed hot water frequently exceeded safe temperatures and prompt action had not been taken to address this, leaving people exposed to the risk of scalding.

People were not consistently protected from hazards that were accessible to them, placing them at risk of harm. This included a cupboard containing personal protective equipment, access to harmful cleaning products and access to an accessible flat roof placing people at risk of falling from height.

Effective systems were not in place to identify and manage the risks associated with fire. An appropriate fire risk assessment was not in place at the time of our assessment and timely action had not been taken in response to recommendations made by the fire service.

However, people and their relatives raised no concerns about the safety of the environment.

The provider did not always make sure there were enough staff available to support people.

Relatives told us there were not always enough staff available to provide support. Comments from relatives included, “When we visit there is only 2 [staff] on shift.” and, “They definitely need more staff, there’s nobody about when I visit.”

Staff we spoke with made reference to the need for more staff to enable them to provide safe, person centred support. Comments from staff included, “The staffing is the same as it has always been. We are a jack of all trades at work. It is very challenging and too much. I raised this in the past and nothing happened. We have just caried on,” “There’s a lot on in the morning. We’re all in 1; cooks, cleaners, carers. There’s only 2 staff. We don’t get stuff done” and, “It is too busy, it is hectic doing personal care, cooking and cleaning.”

The provider did not use an effective evidence based dependency tool to identify how many staff were required to provide safe care and support. They told us they had continued to provide 2 staff members at all times since they became the provider as this was what was previously in place under the previous provider.

Following our inspection, the local authority intervened and placed agency staff at the service to supplement and support the provider’s staff to perform their roles safely and effectively.

However, records showed staff were recruited safely and they received training to provide them with the skills required for their roles. Staff confirmed they completed training.

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.

Effective systems were not in place to manage the risk of infection. A large clinical waste bin was unlocked and the laundry room door was open with large amounts of dirty clothing piled up on the floor. This meant people could freely access items that could expose them to risks of infection. Staff told us the washing machine was out of service due to drainage issues. Following our inspection, representatives from the local authority informed us they had intervened and taken people’s clothing to a laundrette as people were unable to access clean clothes.

Hand gels and soap dispensers were empty in a staff toilet and were not replenished until the inspectors raised this as a concern. This meant staff did not consistently have access to appropriate handwashing after using the toilet, placing them and people who used the service at risk of preventable infections.

However, people and relatives raised no concerns with cleanliness and confirmed staff wore personal protective equipment when required.

The provider did not always make sure that medicines were managed safely.

Staff did not always follow the agreed plans in place to ensure ‘as required’ medicines were only administered as a last resort. During our inspection, we observed a staff member being instructed by a manager to administer an ‘as required’ medicine that had a sedating effect in response to a person’s distressed behaviour before the person’s agreed care plan was followed. This meant this sedating medicine was administered as a first response, rather than a last resort. Records for this person also did not always show this medicine was only given as a last resort, meaning we could not be assured that this person was not being restricted and restrained by inappropriate administration of this medicine.

In addition, the instructions on the medication administration records for this ‘as required’ medicine contained conflicting dosage instructions placing the person at risk of harm from receiving too much of their prescribed medicine.

We found the records of the numbers of medicines at the service did not always match the actual numbers of medicines at the service. This meant we could not always be assured people had received their medicines as prescribed.

However, people and their relatives raised no concerns with medicines management and we found that medicines were stored safely.