Holcroft Grange Residential 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.

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 regulation in relation to the management of risks to people.

This service scored 50 (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's systems were not always reliable to identify and manage some risks and safety concerns effectively, meaning opportunities to make the necessary improvements could be missed. As we were not assured the provider had a proactive enough approach to safety, we could not be assured appropriate lessons were learned.

For example, information about falls was located in several documents meaning it was difficult to track any themes or trends. It was also difficult to track who had been involved in incidents as people were identified by their room number. However, people’s doors to their rooms had 2 differing numbers, one of which was used for fire door identification.

Although the provider operated a ‘Resident of the day’ policy (which provided staff with an opportunity to review individual residents and adapt their care accordingly), the risk assessment and care plan section of some of the reviews were uncompleted, meaning a culture of safety within the home was not always best promoted.

However, staff told us they understood the process for reporting and recording incidents and felt any incidents were discussed as part of their learning.

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.

As risk assessment tools did not correspond to the level of some people’s risks, we could not be assured people’s safety was always properly managed and/or monitored. Some people’s care plans we looked at were inaccurate and inconsistent, so there was a risk people may not receive the care and support they needed as this information had not been captured in people’s plans of care. This meant incorrect or out of date information could be shared with other medical and health and social care professionals involved in the person’s care.

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.

Although we were assured the provider shared concerns quickly and appropriately, we could not be assured they did all they could to work with people to understand what being safe meant to them. It was not evident from some people’s care plans they had consented to their plan of care. Risks for some people had not always been assessed accurately, meaning the safety of people was potentially compromised.

However, staff had a clear understanding of safeguarding and how to keep people safe. Staff knew what action to take should they suspect or witness potential abuse. One member of staff confirmed, “Safeguarding is protecting those who are vulnerable from abuse, harm and neglect.”

People and their relatives told us they felt safe living at Holcroft Grange. One person told us, “Feeling safe is a big aspect of why I like it here.” A relative confirmed, “[Name] is safe because when she is in the lounge, they [staff] are always observing her if she needs anything."

The provider did not work well with people to understand and manage risks. The care provided to meet people’s needs was not always safe and supportive.

Safety concerns were not always consistently identified or addressed. Some risks analysis tools provided unreliable information about the severity of risks to people. For example, we saw how one analysis tool recorded people as being at high risks of falls whilst another analysis tool recorded the same people as being at low risk of falls. As the risk analysis tools were also used to help determine staff dependency levels, this meant there was a risk of harm to people, by not having their risks appropriately recognised and mitigated and not receiving the correct support from staff.

People’s care plans and risk assessments did not always contain consistent or enough information to guide staff on how to mitigate risks specific to them. For example, one person was at risk of urinary tract infections. There was no specific risk management plan in place to advise staff how to support the person to prevent a urinary tract infection.

People’s care was not always provided safely or monitored appropriately to mitigate the risk of harm. For example, for one person requiring a special diet to mitigate the risks of choking, daily care records failed to record their diet, and whether fluids were given to the person at their correct consistency. For example, for one person who was prescribed thickening agent (a prescriptive product added to people’s drinks to minimise the risk of choking) the thickening recording chart recorded incorrect information about the texture of their diet and fluids. This is because the most recent guidance provided by SALT (Speech and Language Therapist) had not been updated on the document.

Information about people’s risks contained in their care plans was sometimes inconsistent. For example, for one person with mobility needs, one part of the care plan recorded they were able to mobilise independently with a walking aid, whilst another part specified the person required staff support.

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.

Whilst the environment was clean and odour free, we observed some areas which were tired and in need of some refurbishment, such as some warped cupboards in the dining room. Some toilet door locks did not work properly and showed them to be engaged when they were vacant. Although the service had pleasant outdoor space to the rear of the home, there was a large pool of water near to one of the benches due to inadequate drainage, making some areas of the garden inaccessible. One person commented, “The garden area where the chickens are is mainly full of pebbles - I would like them to utilise the other green space more.”

We also observed some sluice rooms to be unlocked. As some of the people residing at the home were living with dementia, this posed a risk of harm. We spoke to the manager about our observations; they confirmed a home improvement plan was underway so that improvements could be planned for.

People had emergency evacuation plans in place to assist staff and emergency services to evacuate them safely, in the event of an emergency such as a fire. However, some required further information to ensure people received the appropriate support when evacuating.

We observed call bells in people’s rooms were present and accessible and sensor mats were in operation where required. Regular health and safety checks took place to ensure the environment and equipment complied with health and safety requirements.

Staff received training in fire safety, health, safety and welfare. Fire drills were practiced with staff.

The home had areas which were particularly stimulating for people living with dementia and/or a cognitive impairment. For example, there was a large arts and craft room, a Victorian themed sweet shop, a 50’s Pub, a reminiscence room in the Conservatory, and an ice cream cart.

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.

Although most staff had competed all their mandatory training, some gaps remained, for example, a team leader’s training for fire drills and safeguarding was out of date. However, the manager assured us refresher training had been booked and was almost complete for all members of staff.

Most staff felt there were generally enough staff, but some did mention more staff would improve care—especially on busier days or night shifts. Comments from staff included, “We could do with more staff” and “On busier days I feel like we could benefit with an extra pair of hands.”

Data analysis showed falls were more likely to occur in the home at certain times of the day, such as around teatime and early evening. The manager had recognised this and was in the process of recruiting more staff for busier times of the day.

As some people’s risks had not been assessed at the correct priority, and the risk assessment tool was used to help determine staff dependency levels, there was a risk staff could not be deployed effectively to manage people’s needs.

People and their relatives told us they felt people were cared for by a consistent staff team and there was enough staff. One person told us, “I know the faces the names of all the staff and they know what I need.” A relative shared, “[Name] seems to recognise all of the staff, and she gets on very well with them” and “I think there is enough staff."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff completed appropriate training in infection prevention and control, food hygiene and were aware of safe hygiene practices. Personal protective equipment (PPE) was available for staff to wear when providing support.

Regular audits of the home’s environment and equipment were completed to ensure it was clean and well maintained. People and their relatives told us they thought the home was kept clean. One person said, “They [domestic staff] are forever cleaning the place.” A relative told us, “The place is spotless."

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

Some people were prescribed medicines to be taken ‘when required’. The protocols to support the safe administration of these medicines where not personalised meaning staff did not always have sufficient guidance to follow to help them decide the most appropriate way to give these medicines. This placed people at risk of not getting their medicines consistently and at the time they were needed.

However, the provider had already identified this and was in the process of taking action to improve people’s ‘when required’ medicines protocols.

Some people were prescribed thickening powders so drinks could be served at a safe consistency to lessen the risk of choking and aspiration. However, staff were not recording when this was being administered in people’s drinks. This is important as in the event of a choking incident, there would not be a reliable record the person had received their drink as prescribed by the dietician.

Some people’s medicines care plans required further detail to help better guide staff. For example, for one person who was prescribed a topical patch, guidance was missing for staff about how the patch required rotation to a new part of the skin on each application.

However, we were assured staff were administering medicines in line with best practices. People told us they thought they had the support they needed with regards to their medicines. One person told us, “The staff help with all my medication. I get it on time. I can’t complain about how that is organised."