Fort Horsted Care Home Ltd

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 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 continued breach of legal regulation in relation to people’s safe care and treatment including the ways people’s medicines were managed safely.

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 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.

Although incidents, accidents and safeguarding concerns were recorded, actions were not always documented or monitored. This meant the provider could not be assured that learning always took place and led to sustained improvement. Learning that had taken place following some incidents was not always embedded into practice. For example, lessons learned following a medicines error focused on staff being “more vigilant” but did not evidence reassessment of staff competency or changes to systems to prevent recurrence. Prior to our inspection, CQC had reminded the registered manager of the requirement to ensure timely reporting of possible safeguarding concerns. Management had completed a lesson learnt with staff and at this inspection, staff told us they understood the importance of reporting incidents. However, records showed repeated themes, including delays in reporting safeguarding concerns, which evidenced learning was not consistently applied.

Despite the inspection findings people’s relatives described good communication when incidents occurred, including prompt telephone calls and clear explanations of actions taken. A relative told us, “There has never been any concern for me – [Person’s Name] is safe here."

The provider had not always work well with people to establish and maintain safe systems of care when they moved into the service.

The provider had systems in place to support people to move safely between services, but these were not always fully effective. Pre-admission assessments took place with people. A person told us, “They came to meet me at home and discussed my needs. They did my care plan and talked about my likes and dislikes.” A relative said, “They made an appointment and we got a pack which explained everything we then went on to discuss the care plan and risk assessment.” However, we found a person had been living at the service for 22 days but some of their assessments and care plans had not yet been completed, including essential information in relation to the persons environmental safety and physical health. This meant the provider had not always managed or monitored the person’s safety.

The provider made sure there was continuity of care when people moved between different services. People’s care records included hospital packs so important information about people could be shared between services when required. Staff worked with health professionals such as GPs, dietitians, and specialist nurses to support continuity of care. Staff communicated with relatives when people became unwell, and relatives confirmed they were kept informed during hospital admissions and incidents.

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. The provider did not always share concerns quickly and appropriately.

Safeguarding systems were not always effective in protecting people from harm. We identified safeguarding concerns that had not been raised promptly nor escalated appropriately. In some cases, safeguarding referrals had only been made after internal investigations, which limited timely external oversight. The provider acted following the inspection to implement a system to ensure timely reporting of possible safeguarding concerns.

Records of lessons learned following safeguarding incidents did not clearly demonstrate how practice had changed to reduce future risk. Staff had received safeguarding training and could describe their responsibilities, but inconsistent reporting practices reduced assurance that people were fully protected.

Despite the inspection findings, people and relatives felt the service kept people safe. A person said, “I do feel safe here.”

Staff had made Deprivation of Liberty (DoLS) applications to the local authority to deprive some people of their liberty. 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 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. There was a tracker in place to monitor when these had been approved or were due for renewal. This was to ensure any restrictions were lawful, proportionate, and in the person's best interests.

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 and supportive.

People did not always receive support in line with their risk assessment or care plan in order to keep them safe. In some cases, risks such as nutrition, constipation and pressure care were not effectively monitored or escalated. For example, people at risk of dehydration were not always offered enough fluid to meet their individual fluid target and we found some people were frequently not meeting their targets. This placed people at potential risk of harm.

Three people had been experiencing constipation; we found that this had not been identified by staff or escalated for treatment. This placed people at risk of harm.

Some people’s care records stated they needed support with repositioning, however, records demonstrated that people were not always been repositioned in line with their planned care.

People’s care records also did not always contain sufficient detail to guide staff on how to provide people’s care and support safely. For example, people who had diabetes did not always have clear guidance in place to support staff to identify changes in their condition or how to provide treatment to maintain safe blood sugar levels for people. This meant there was a risk staff would not know how to support people safely and their health could deteriorate.

Not all risks for people had been assessed as required such as risks in relation to medicines which increased people’s risk of bruising or internal bleeding or risks in relation to fire for people who used flammable creams. This meant risk monitoring and mitigation had not been planned in relation to these risks and placed people at risk of possible harm.

The provider immediately started reviewing people’s care records to ensure they contained all required information in relation to people’s current needs. They had a plan in place to continue to do this until all people’s records had a detailed review completed. We will review this at our next inspection.

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.

The environment had not always been well maintained although some improvements were underway. The provider had invested in refurbishments, and many people and relatives commented positively on improvements. However, we found some environmental checks had not been completed at regular intervals such as weekly fire call point testing, weekly emergency lighting checks and weekly gas shut off checks. Inconsistent management oversight of the environment and gaps in recorded actions following audits meant the provider could not be assured that all environmental risks were effectively monitored and promptly mitigated. The provider told us an additional member of staff would temporarily support the service to ensure maintenance checks took place as required.

Other checks such as electrical safety, legionella and equipment checks of slings and hoists had been completed as required. We observed people’s pressure relieving equipment was set correctly to mitigate risk to their skin integrity. People told us staff used required equipment to help them mobilise. A person told us, “They ordered me a new slide sheet because mine was thinning."

The provider had not always made sure there were enough qualified, skilled and experienced staff. However, they did make sure staff received effective support, supervision and development.

The provider did not always ensure there was safe and effective staffing at the service. Although rotas showed planned staffing levels were being met, we received mixed feedback about staffing levels. Some people fed back that they did not feel staffing was sufficient at all times of day to meet their needs or the needs of others in a timely manner. A person said, “I use the call bell if I need the commode, they come as quickly as they can, I had to wait an hour last night because all commodes were in use. It was getting urgent. Mornings there is not enough staff and evenings – I have to wait in the morning which I find the worst, all staff are busy with others.” Another person said, “At night 1 nurse and only 3 carers and you have all these people to sort out. Sometimes you have to wait a long time maybe just 1 more staff member maybe would give some help.” Relatives also gave mixed feedback. A relative said, “There is enough staff.” Whereas another relative said, “They could do with a couple more pairs of hands. This is just sometimes nothing that has made me be concerned.” Call bell monitoring records showed that there were times during the day and overnight where people were experiencing longer wait times. The registered manager held a meeting with staff to discuss this and put a plan in place to try and reduce wait times. We will check this at our next inspection.

Recruitment practices had not always been robust. The provider’s recruitment processes had not requested staff’s full employment history. We found some gaps in recruitment records such as no reason recorded for why staff left previous employers and the service had not received references for some staff’s most recent employer. We fed this back to the provider who updated their application forms immediately to address this.

Staff training and supervision was ongoing.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Infection prevention and control (IPC) practices were not consistently effective. On our arrival to the service, it was not visibly clean. Staff told us there had not been a cleaner the previous day. We also observed worn and damaged furniture that posed infection risks for people.The registered manager was aware of these concerns and was ordering new furniture in stages to address the infection control risk. Throughout the day we observed cleaning taking place and the home appeared clean.

Although cleaning schedules were in place, staff told us there was 1 domestic staff for cleaning per day and 1 for laundry. Some staff told us they felt the service would benefit from an extra member of staff to ensure all essential cleaning could be completed daily. Some relatives raised concerns about cleanliness in specific areas, including dust and laundry processes. Records showed IPC audits took place however some actions were carried forward without timely completion. These inconsistencies meant the provider could not fully demonstrate robust infection prevention.

We observed staff completed hand hygiene practice and used personal protective equipment as required when administering care, food, and medicines.

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

Medicines were not always managed safely. Electronic systems supported medicines administration, and some people and relatives reported confidence in how medicines were given. A relative said, “I have witnessed them giving medicines and they watch over as she takes it as well as wear PPE.” People told us they were supported with their medicines and could have certain medicines when required such as for pain relief. However, ‘as required’ medicine such as medicines prescribed for relief from constipation had not been administered in line with people’s care plans and PRN protocols. We found 3 people had experienced recent constipation, 1 for a period of 7 days and another for 4 days and they had not received their prescribed medicines to treat this. Another person experienced constipation for 4 days and this was not referred to the GP to review whether a prescription to manage their condition would be appropriate.

We also identified some concerns, including medicines given outside prescribed schedules, missing or incomplete PRN protocols and discrepancies in stock counts. Lessons learned from medicines errors were not consistently translated into strengthened systems or staff competency checks. These issues increased the risk of medicines-related harm.

Medicines had been stored and disposed of safely and staff had received appropriate training to administer medicines.