The Headington 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 inspection for this newly registered service. This key question has been rated 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 medicines management, infection prevention and control, safeguarding, and good governance.

This service scored 56 (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 encouraged a safe culture, 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 practice.

Staff reported safety events, and investigations were undertaken to establish cause, and identify lessons learnt. Staff told us they were debriefed after incidents. Learning was discussed in staff meetings, handovers and supervisions to ensure practice was embedded. The registered manager told us, “We know staff have listened as we observe and ask them questions on daily walkarounds of the service, or they will ask us questions.”

Records showed learning was shared widely across the staff team, and across services managed by the same provider. People told us they felt safe in the service, however, their relatives provided mixed feedback.

One person’s relative told us the provider communicated with them when their relative experienced an adverse event, “I get a phone call if [they have] fallen, a description of what happened, what the process thereafter is, and when the GP is being involved to check him over.”

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 worked in partnership with the local GP and other healthcare professionals to support safe transitions between services, including collaboration with the community discharge team following hospital stays. The service had recently changed staff allocations for people who were staying in the home on a temporary basis, resulting in improved continuity of care for people and consistent communication with the community discharge team.

People were supported to attend medical appointments. The provider completed pre-assessments with people moving to the service so they could understand people’s needs. However, the quality and detail of these assessments varied.

The provider acted in response to feedback from external professionals. For example, implementing staff training to improve communication.

The provider did not consistently work with people or healthcare partners to understand what safety meant for individuals or to uphold their right to live free from abuse, neglect, discrimination and avoidable harm. Concerns were not always shared promptly or appropriately.

During the inspection, we observed an incident where a person was put at risk because essential equipment and required staffing support was not used as written in their care plans and risk assessments. Records evidenced that visits had taken place prior to our inspection and did not identify that the person’s risk assessments were being adhered to. The service failed to recognise or challenge unsafe treatment delivered by the external provider to the person that had been taking place within the service. The service had not liaised with the family, which meant there was a missed opportunity to support coordinated and safe care with the external provider. This resulted in a safeguarding concern.

A person’s bruising was not recorded or handed over between staff, and incidents of their distressed behaviour were not documented. Another relative told us [about a loved one’s bruising], “Apparently no one had seen it. The [registered manager] said [they] will check with [staff] and then get back to me but of course they haven’t.”

The service had identified through audits and team meetings that staff lacked confidence in recognising and reporting abuse. The provider had arranged face-to-face training to help improve staff knowledge. The provider applied for Deprivation of Liberty Safeguards (DoLS) and supported people with DoLS appropriately.

The service did not identify that people were receiving excessive medication or safeguard them from this.

While the service made safeguarding referrals and notified the Care Quality Commission (CQC) as required, care plans and risk assessments did not always contain up‑to‑date or detailed information about current safeguarding concerns. This meant staff may not always have access to information they needed to keep people safe.

The provider did not consistently work with people to understand and manage risks, and staff did not always deliver safe, supportive care that enabled people to do the things that mattered to them.

Risk assessments were not always personalised and did not always contain information staff needed to manage risks to people. For example, guidance was not always available in relation to people’s health conditions, weight management and mobility needs. One person’s risk assessment did not identify their reduced food intake, its impact, or what action staff should take. A staff member told us, “We have less time to prompt for those who have low appetite and for those who are agitated.” This meant the provider could not be assured all risks were consistently identified, monitored or managed, reducing the provider’s ability to ensure safe and effective care.

The provider did not always work in partnership with people when assessing and managing risk; care plans and risk assessments were not always discussed with people or their representatives. One person’s records said they could manage their own continence but wished to wear a continence aid, although this had not been discussed with them. Another person’s continence information did not align with their relative’s understanding about their needs. These inconsistencies meant people and their relatives were not given the opportunity to make informed choices about risks posed to them.

We observed some examples of safe practice, including staff using equipment and supporting people to mobilise in line with their assessed needs. Staff handover meetings were informative and helped identify people at risk.

One person’s relative told us, “[they] were having falls when [they] first moved in, they have introduced fall mats and buzzers under [person’s] seat and there have been no falls since last September.” Another person’s relative told us about their loved one’s positive experience in being involved to manage the risks posed to them due to their care needs. However, another relative responded “Safe? No, [person] isn’t because there are several other people who wander into [their] room and that is a big worry for [them].”

This meant some people had a safer experience in the home than others.

The provider did not always identify or manage environmental risks, and some equipment, facilities and technology did not fully support safe care.

Several rooms within the home were observed to be cluttered with a mixture of old and new equipment, along with paperwork and boxes, which meant these areas were not readily accessible. This may increase the risk of fire spreading more easily. In addition, some people’s bedrooms contained boxes and items stored on top of wardrobes, presenting a potential risk of items falling and causing harm. However, no evidence was found to indicate that this has occurred.

Communal areas and external access to the home were not well managed due to uneven paving, weeds and moss, discarded old pots and old furniture placed outside. This created trip hazards for people who used the communal areas independently. Staff supported people who needed assistance by guiding them to safer, flat areas.

The service’s fire bag was missing radios and an up‑to‑date resident list and business continuity plan. This meant people were at risk of harm in the event of an emergency. We gave feedback to the service, and they were replaced during the inspection.

Personal Emergency Evacuation Plans (PEEPs) described people’s locations in the building and evacuation needs.

Maintenance checks were regularly completed, and the on‑site maintenance team was responsive and worked safely. Equipment such as hoists, wheelchairs and pressure‑relieving mattresses was routinely checked, helping to ensure people remained safe when using assistive equipment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

The provider used a dependency tool to calculate staffing levels, however, rotas evidenced that there was not always the number of staff required on shift.

Staff provided mixed feedback about staffing levels. They told us mornings and evenings were particularly difficult due to workloads, and they were often short staffed and reliant on agency workers. One staff member said they felt “exhausted and burnt out.” Other staff members reported staffing levels were managed well by senior leadership, ensuring cover from agency staff when required.

People told us there were not always enough staff, and that workloads felt high. Relatives provided mixed feedback about staffing levels. Comments included, “There is usually enough staff around”, “Numbers seem to vary to be honest, but I would say overall that they have been understaffed. They have agency [staff] in quite often too,” and “My other main issue is that there are not enough staff.”

Professionals told us, “[We] would welcome a review of staffing ratios to allow more time with people” and, “Staff are very busy, we can’t always find someone to help us.”

The management team told us, “When the activities coordinator is carrying out 1 to 1 sessions, we encourage carers to provide communal activities.” We also observed non‑care staff regularly carrying out care tasks not within their responsibilities to support care staff’s workload, although trained to do so. This reduced time available for their own responsibilities, impacting cleaning, care, and coordinating activities. We gave feedback to the provider about service cleanliness and activity provision.

Staff recruitment was managed safely with all required checks in place. Staff received regular supervision and relevant training and told us they felt confident in their roles. Staffing concerns had been raised in supervision, and management had offered support for staff wellbeing. The provider acknowledged that sickness and vacancies had impacted staffing levels in the service. The use of agency staff remained regular, though the provider told us this was beginning to stabilise due to new permanent staff and increased use of bank staff.

The provider did not always assess or manage the risk of infection. Areas of the environment were visibly unclean, including stained floors, marked skirting boards and worn and marked upholstery. Less used kitchen areas were also poorly maintained, and high touch points such as light switches, door edges and handles had visible residue. Some metal cutlery was also visibly unclean.

Food and drink items in communal and kitchen areas were not consistently labelled with opening or use‑by dates. Staff did not always wash their hands between tasks, particularly when serving food or administering medicines. These issues increased the risk of cross-contamination and people consuming food that was no longer safe to eat. We gave feedback to the provider and hand hygiene practices improved over the following visits.

When the provider had identified potentially infectious illness, they had successfully prevented this spreading across the service. A case of influenza had been isolated effectively and did not spread.

Staff used Personal protective equipment (PPE) correctly and disposed of it safely, and people were offered hand wipes before meals. Assistive equipment and kitchen equipment in frequently used kitchens were clean.

The provider did not ensure medicines and treatments were always safe or aligned with people’s needs, or preferences, and people were not fully involved in planning.

Care plans did not always contain clear guidance on what medicines people were prescribed, or how side effects affected people’s daily lives. A relative told us, “There have been occasions when a [staff member] has missed [giving medicine] altogether and a few occasions when incorrect meds have been given, but that has settled down and become a lot better now.” We found staff had administered medicines incorrectly to 3 people. In response to our findings, the provider investigated our concerns and identified a further 20 people had been impacted by medicines errors. This meant people were at increased risk of avoidable harm.We did not identify that people had suffered harm as a result of these errors. The provider introduced measures and shared learning to prevent recurrence.

The provider had failed to ensure prescribed wound treatments and fortified milkshakes were consistently stored securely. This meant they were accessible to other people in the home and created a risk of accidental consumption. In response to our feedback, the provider ensured items were stored securely.

Medicines were otherwise stored correctly. Staff completed stock counts, and Medicine Administration Records (MARs) were managed appropriately. Staff received medicines training and competency assessments. People taking anticoagulants had risk assessments, and interim care plans were in place for those prescribed antibiotics.

Staff supported people to take their medicines with a person-centred approach. One relative told us, “[Person] doesn’t like taking [their] meds sometimes but they [staff] reason it out with [them] and assure [them].”