Hyde Lea

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 requires improvement. At this assessment the rating has remained as 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.
 

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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.

We found that incidents relating to the safe care and treatment of people were not consistently investigated or reported in line with regulatory requirements. Audits of accidents and incidents were not consistently completed, preventing recurring themes and patterns being recognised and acted upon. This meant learning opportunities to help improve staff knowledge and skills were not provided ensuring best practice followed.
We spoke to the new manager who explained how she planned to address this and had started to implement new processes and ways of documenting and reviewing accidents and incidents.

Reviews of falls had now taken place, and a new accident and incident form had been created to ensure appropriate review and action is taken following a safety event.

Team meetings have been scheduled to ensure staff are aware of the expectations regarding the new processes and approach which will have a stronger focus on learning and improvement.
 

We did not look at Safe systems, pathways and transitions during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safeguarding during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

The provider did not always work well with people to understand and manage risks. 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.
Care plans contained some information about people’s individual risks but there were not sufficient risk assessments in place to reduce and manage risks to people. One person who had fallen frequently did not have a risk assessment or suitable equipment in place to help to reduce their risk of falls. In addition, the provider was not aware that this person had fallen several times.
We spoke to the new home manager who had already started to review risks to people and create the necessary risk assessments that were needed to keep people safe. During our second day at the home, we observed the necessary equipment in place to monitor people and help to reduce their risk of falling.
An area of concern identified during our assessment was the door leading to the 2nd floor where some residents’ bedrooms were located. This door was unlocked and led to a small flight of stairs. The risk this posed to residents, particularly those on the second floor who were a falls risk, had not been identified or assessed.
We spoke to the provider and the registered manager about this and asked that action was taken to ensure people’s safety. A suitable door lock, that also complied with fire regulations has since been purchased and is awaiting installation. We have asked the provider to confirm when this has been installed
 

We did not look at Safe environments during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

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.

People were recruited safely with the necessary checks in place. Staff received the necessary training and said they felt supported in their roles. A review of rotas showed adequate staff members were available during the day. However, during our assessment we identified that falls were more frequent during the evening. We discussed this with the provider and new home manager. The manager said they were looking into scheduling an extra member of staff during this period to ensure there was sufficient oversight throughout the home.

Staff had not been receiving regular supervisions or one to ones when we visited the home. We spoke to the new manager who said they planned to start implementing these. The manager also shared their plans and format for regular team meetings which included discussion of the issues identified during our assessment.
 

We did not look at Infection prevention and control during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.