Hope Valley Nursing 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 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 people’s safe care and treatment, staff training, person centred care and governance at this inspection.

This service scored 47 (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. Effective systems were not in place, and lessons were not learnt to continually identify and embed good practice. The provider had not reviewed accidents and incidents prior to our inspection, nor had they carried out any analysis to identify themes or trends to prevent further risks to people’s safety. Following our inspection, leaders completed an audit of accidents, incidents and falls. However we found this did not include all relevant events, or provide a robust analysis this placed people at risk of harm.

We received mixed feedback from people, and relatives on the management of incidents. Some felt the provider’s approach was reactive, others felt the provider was proactive at managing immediate risks, such as implementing sensor mats or moving to a safer bedroom.

Not all relatives felt fully informed when their loved ones were involved in an accident, incident or fall. Some feedback included, “They say that they don't know how [bruising] occurred or what [person’s] been doing, and they don't offer explanations.” Another told us, “When I speak to them about these incidents, they say that they don't know how they occurred or what he's been doing, and they don't offer explanations.” Leaders informed us that a resident of the day initiative would be implemented. This would aim to improve involvement and communication with relatives regarding their loved ones care and support, including any accidents and incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They supported people to make sure there was continuity of care, including when people moved between different services. There was a pre-admission process in place to ensure a safe transition into the home. Staff confirmed information about new placements was shared with them, and that care records provided sufficient information to know people’s needs and preferences. Leaders worked with professionals involved in peoples care, to ensure accurate information was shared to support a safe transition.

People and relatives shared positive examples of how the provider eased the transition into the home. For example, “[Person] has a quite spacious room overlooking the outside and was able to bring a lot of their own belongings and they asked if there was anything that we wanted changing about the layout or décor of the room.” Additionally, the provider worked with people and relevant services to support transitions into more independent living where appropriate.

There was no effective system in place to review accidents and incidents, this meant safeguarding concerns were not always quickly identified and shared appropriately. During our inspection we identified 1 safeguarding concern which had not been identified or raised by the provider’s own systems. Action was only taken after raised by the inspection team. This meant we could not be assured the providers systems and processes ensured people were fully protected from the risk of abuse, or harm.

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. We found that systems were in place to ensure appropriate deprivation of liberty safeguards were applied for and monitored as required.

Overall, risks to people were identified and assessed. Some improvements were required to ensure timely reviews of risk assessments as people’s needs changed, such as following a fall.

However, 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. Feedback from relatives indicated that people’s risks were not always safely managed. For example, “We have not been so happy with the way the carers have used the equipment as I'm not sure they are all well trained in it and one of them was quite sharp with [person] which they didn't like.” In addition, one relative told us staff had contacted them to ask what to do when their loved one experienced a seizure. This raised concerns that staff had not been provided with adequate guidance, or training on how to respond to seizures. Leaders confirmed additional training had been sourced and booked.

Where people communicated signs of distress, care plans generally provided sufficient guidance to support people safely. This included potential triggers, how people’s behaviour may present and how staff should respond. Some people required one to one support due to risks associated with them displaying signs of distress. Whilst this support was consistently provided, and staff recorded their interventions, including any behaviour related incidents, these were not reviewed by leaders to ensure the support remained effective and appropriate.

While the physical environment and equipment was observed to be safe during the inspection, the provider's recording and documentation of environmental checks were disorganised and inconsistent. This lack of reliable records meant we could not be assured that governance systems provided effective oversight of premises and equipment safety.

During the inspection, we observed that there were sufficient staff on site to meet people’s needs. Systems were in place to calculate safe staffing levels based on the needs of people using the service. However, feedback from both staff and people using the service indicated that staffing levels were not consistently adequate, particularly during nights and weekends. Concerns were raised about delays in care and reduced responsiveness during these times, which impacted the overall quality and continuity of care. One relative told us, “Staff are very rushed, and they don't have time to do things.” And “I do think that they are short of staff and particularly at the weekends, there were not many staff at all.” A staff member shared, “At nights, I do not feel like there is a good staffing level and I feel like there should be an extra staff member in each floor out of safety for the residents.” Leaders explained ongoing recruitment to ensure a full permanent staff team, as well as establishing senior roles and responsibilities would alleviate pressures on the staff team.

The provider’s training matrix showed that not all staff had received the necessary training to carry out their roles effectively. This placed people at risk of receiving unsafe care. The provider responded immediately and confirmed relevant training courses had been booked in for staff following our inspection.

During the inspection, the home was observed to be clean, and domestic staff were visible and actively engaged in cleaning tasks throughout the day. However, governance arrangements around infection prevention and control (IPC) were not effective. There were no IPC audits in place, and the manager did not routinely review cleaning schedules to ensure they were being followed or updated appropriately. This increased the risk of infection.

The provider did not ensure the safe management of medicines, and that medicines met people’s needs, capacities and preferences. During the inspection, we identified discrepancies in medicines stock, which meant we could not be fully assured that people had consistently received their medicines as prescribed. This placed people at risk of deteriorating health and wellbeing.

Additionally, reasons for administering, and the effectiveness of ‘as required’ (PRN) medicines were not always recorded. For example, when people were administered medicines to manage signs of distress, there was a lack of documentation to demonstrate what approaches had been tried prior to administering medicine, or the rationale as to why the medicine was administered, and whether the medicine had the desired effect. This meant we could not be assured the medicines had always been administered appropriately, and whether there had been any patterns in the usage which required further clinical review.

Following our inspection, a full stock count was carried out and on our second site visit we found discrepancies had been rectified, as well as the introduction of a medicine error reporting system. A clinical lead was new in post at the time of our inspection, and the provider explained their role going forward would include oversight of medicines.

Medicines were stored safely and ordered and disposed of in line with relevant best practice guidance.