Hodge Hill Grange

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 good.

This meant people were safe and protected from avoidable harm.

This service scored 63 (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 had a proactive and positive culture of safety, 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 good practice.

There was a structured approach to reporting and reviewing incidents and accidents. These were recorded by registered nurses and senior care staff using the provider’s electronic risk management system and overseen by the registered manager, with final sign‑off completed by the area manager. Staff demonstrated a clear understanding of how to report incidents and told us they received regular feedback and opportunities for learning and improvement from the registered manager.

The registered manager described the processes in place to share lessons learned and provided examples of how learning had been embedded into day‑to‑day practice to help reduce the risk of similar incidents occurring in the future. Systems were in place to document lessons learned, which were disseminated through daily flash meetings and routine staff meetings. Learning was also logged on the provider’s electronic staff scheduling system, which all staff could access, ensuring consistent communication and awareness across the workforce.

There were some gaps in repositioning records where staff had not consistently logged entries on handheld devices. The registered manager had already identified this through audits, and staff had been reminded to ensure accurate documentation. Other records confirmed care had been delivered, and there was no evidence of harm. The provider’s action plan included required improvements with timescales, and issues identified during this inspection had been added for ongoing monitoring and service improvement.

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.

We reviewed pre‑admission assessments completed before people moved into the service and noted 2 different versions in use. Some assessments contained gaps and lacked detailed information about people’s life histories and health conditions. However, a recent new admission showed that the updated pre‑assessment had been fully completed and uploaded onto the provider’s electronic care management system. The service now needs to fully adopt and embed the new pre‑assessment process to ensure comprehensive information is consistently gathered to support the development of robust, person‑centred care plans.

Staff told us they felt well supported when welcoming new people into the service and had access to the information they needed. Key updates were communicated through daily flash meetings and the communication log.

People were supported to attend external healthcare appointments, and referrals to other professionals were made when required.

Care plans did not always contain essential guidance for staff regarding how to support people with their diagnosed health conditions. Despite this, staff described knowing people well, and we observed care being delivered in a responsive manner that reflected an understanding of people’s individual needs.

The registered manager acknowledged the shortfalls in some support plans and had begun addressing these as part of the assessment and review process. They also described how they will be overseeing the new pre‑admission procedure to ensure a smoother transition for people moving into the service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The registered manager understood their responsibility to report safeguarding concerns to the appropriate authorities. Safeguarding incidents had been logged, investigated, and where required, referrals were made to the local authority and notifications submitted to CQC. Investigations were recorded on the provider’s electronic risk management system, along with actions taken.

People told us that they felt safe living at the service. One person told us, “I feel safe. I don’t have to worry about anything.”

Staff demonstrated good knowledge of safeguarding and the different types of abuse. They told us they felt confident to raise concerns with the management team and were able to describe scenarios where they would follow the provider’s safeguarding policy and procedures. Staff had received safeguarding training relevant to their role.

Deprivation of Liberty Safeguards (DoLS) applications were completed when required, and a monitoring system was in place. Restrictions such as locked doors were recorded, and staff considered the least restrictive options wherever possible. There was evidence that Mental Capacity Act (MCA) assessments and best‑interest decisions had been completed for specific matters, such as the use of sensor mats or situations where people were unable to use call bells. However, these decisions were not always consistently documented or updated within people’s care plans. The registered manager acknowledged this shortfall and began addressing the recording gaps during the inspection.

Throughout the inspection, we observed positive examples of staff supporting people safely. Our review of safeguarding processes confirmed that ongoing and completed safeguarding incidents were managed effectively, with outcomes and actions clearly documented.

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.

We found people living at the service with complex dementia care needs, some of whom could experience heightened anxiety or agitation. However, support plans did not contain sufficient detail about individuals’ known triggers, or the diversion and de‑escalation techniques staff should use to support them safely.

Individual risks were not always effectively mitigated. For example, 1 person’s care records stated they required a level 7 “minced and moist” diet, but during lunch we observed they were served whole sprouts, which presented a potential choking risk.

Care plans did not consistently provide the guidance staff needed to manage specific health‑related risks. This included insufficient information relating to oxygen use, catheter care, skin integrity, and diabetes management. As a result, staff did not always have clear, up‑to‑date instructions to support safe and effective care delivery.

Although the provider had processes and procedures for assessing and monitoring risks, these were not always robust or effective in practice. We identified concerns in relation to elements of fire safety, restricted access to high‑risk areas, infection prevention and control standards, waste disposal, and the effectiveness of maintenance arrangements. Risks associated with people’s health conditions were also not always managed safely.

Despite these concerns, we observed staff actively present in communal areas, monitoring people and responding in ways that helped to keep them safe and mitigate immediate risks.

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.

We identified several environmental safety risks during the inspection. A sluice room on the nursing floor was left open despite other key‑coded areas being secure. Thickener was found unsecured in a kitchenette, creating an asphyxiation risk, and a hot food trolley containing hot water was left unattended, posing a scalding risk to people with cognitive impairment.

Microwaves and electric kettles were accessible without risk assessments, creating potential burn and fire hazards. Stained plastic beakers and areas requiring deep cleaning, along with chipped furniture, indicated gaps in infection control. Refurbishment work had begun but several areas, including bathrooms, remained outstanding as the provider was in a period of transition.

Radiator covers were missing; however, an engineer confirmed the radiators were safe and within temperature limits. Fire drills consistently took 7–9 minutes, but this had not been recognised or acted upon. External clinical waste bins were found unlocked, creating risks of tampering or exposure.

The management team responded promptly to the immediate risks identified. The kettle and microwave were removed from the dining room kitchenette, and staff were instructed not to bring the hot trolley upstairs until food was ready to be served and staff were present to supervise. Staff were also reminded that all sluice rooms must remain locked. Clinical waste bins were now secured behind locked gates. This information was disseminated to staff through flash meetings and direct supervision. The management team demonstrated a clear understanding of the risks identified and took swift action, and inspectors were assured that ongoing monitoring and strengthened oversight would help mitigate future risks.

Equipment such as hoists and individual slings was well‑maintained, and staff were knowledgeable about fire procedures. Despite the concerns we found, people and relatives told us the home felt clean and safe.

The provider ensured there were enough qualified, skilled and experienced staff who received support, supervision and development. They worked together well to provide safe care that met people’s needs.

Staffing levels were safe, effective and responsive, and we observed good deployment throughout the inspection. Staff were visible, attentive and available to offer support when required. People were supported by kind and caring staff, and interactions were warm, respectful and person‑centred.

People and their relatives told us they were usually supported by a consistent group of familiar staff who knew them well and understood their risks. Most people and relatives felt staffing levels were appropriate, although 1 relative commented that staffing felt lower at weekends. Another relative reported earlier difficulty in communication with nursing staff; however, they confirmed this had been raised with the registered manager who resolved the issue promptly.

Throughout the inspection, people appeared relaxed and comfortable in the presence of staff. Relatives praised the staff team, with 1 relative saying they felt there were enough staff, whatever time or day they visited and that staff were well trained and knew what they are doing. Another relative commented, “Staff are always looking around her [loved one’s] bedroom door as she cannot use call bell and there are always staff in the lounges.” Staff also confirmed that management responded flexibly to changes in need, with 1 staff member telling us, “If I need any help the seniors will jump on and straight away to help me.”

The registered manager used a dependency tool to determine safe staffing levels, and rotas reflected people’s assessed needs. Staff demonstrated good knowledge of the people they supported, as evidenced by positive interactions observed during the inspection. Hourly observations had been implemented for people who chose to remain in their rooms and did not use call bells, helping ensure their safety.

Recruitment practices were safe and robust. Appropriate pre‑employment checks including references and Disclosure and Barring Service (DBS) checks had been completed to ensure only suitable individuals were employed. Record‑keeping for more recent recruits had been strengthened, and recruitment processes were overseen by the provider’s head office.

Staff described a thorough induction programme and told us they received regular supervision, appraisal and competency assessments. Training was monitored via a training matrix reviewed by the registered manager, and staff were given time on the rota to complete required learning. One staff member told us their training was “effective” and had supported them “to respond to people’s care needs in the moment”.

Staff also felt supported in their professional development, with several progressing into senior roles with the backing of the management team. The provider’s recent staff survey indicated staff felt valued, supported and confident in the registered manager’s decision‑making. Most reported positive teamwork and good access to training and supervision.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service had an up‑to‑date Infection Prevention and Control (IPC) policy and procedure in place, which had been regularly reviewed in line with national guidance. Routine IPC checks and audits were completed. Staff were observed to be ‘bare below the elbows’, performing hand hygiene appropriately, and using personal protective equipment (PPE) correctly. PPE supplies and cleaning products were well stocked, and cleaning trolleys were equipped with colour‑coded materials. Handwashing facilities and hand sanitiser stations were available throughout the home.

Domestic staff were observed cleaning throughout the day, demonstrating an ongoing focus on hygiene. A “resident of the day” system ensured people’s rooms were deep cleaned on a rotational basis. We also saw that each person had an individually named sling, and slings were on a scheduled washing rota. When a person requested a room move, the room was deep cleaned before they transferred.

However, some areas of the home required a deep clean, including high‑touch points, and several pieces of furniture were chipped, creating potential infection harbourage points. The provider had an environmental improvement plan, including redecoration and refurbishment, though progress had been paused due to the pending sale of the home. We also noted that some posters in the treatment room were not laminated and that corridor decorations would need to be removed in the event of an infectious outbreak. In the second‑floor kitchenette, we found discoloured and stained plastic beakers, which did not meet IPC standards.

The service had appointed an IPC Lead who had recently moved into the role. Records confirmed they had completed IPC training; however, the IPC Lead did not yet demonstrate sufficient knowledge or confidence to fulfil the full requirements of the position. In response, the provider arranged enhanced on‑site IPC training and mentoring support from an IPC Lead at a sister home, including shadowing and implementation of more robust audits and monitoring tools.

Clinical rooms were clean, organised and aligned with best practice. Clinical equipment was clean, correctly stored, and ready for use. Notices were displayed in reception advising visitors with symptoms of illness not to enter, supporting the provider’s approach to reducing infection risks.

Relatives did not raise concerns about day‑to‑day cleanliness; however, several highlighted that some areas required redecoration or replacement of worn furniture.The provider was receptive to inspectors’ feedback and took immediate action during the inspection to address several concerns. However, not all issues had been identified through the service’s own internal monitoring. The management team now need to ensure that all improvements are completed, monitored effectively, and embedded into routine practice to sustain safe IPC standards.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Clinical treatment rooms were found to be well maintained, clean, and compliant with requirements for safe storage of medicines. Rooms and medicine trolleys were kept locked when not in use, and records showed appropriate monitoring of room and fridge temperatures. Systems for ordering, storing, and disposing of medicines were well managed.

Reviews had been completed for 3 people prescribed antipsychotic medication within the last 3 months by the psychiatrist. Time‑specific medicines, including those required before breakfast, were administered as prescribed for all 3 relevant individuals.

PRN (as‑required) protocols were in place; however, the quality was variable. Some protocols provided clear and prescriptive guidance, while others required strengthening. For example, 1person prescribed lorazepam had a PRN protocol in place with no instructions regarding dose or frequency beyond “if needed,” which did not provide staff with sufficient direction.

Medicines requiring specific administration techniques were managed safely. Alendronic acid was administered correctly, with evidence that the person remained upright for 30 minutes following administration.

Covert medication arrangements were in place for 2 people, supported by Mental Capacity Act assessments, best‑interest decisions, pharmacist involvement, and consultation with GPs and next of kin.

Insulin was administered safely and in line with best practice. Injection sites were clearly recorded and rotated appropriately to reduce the risk of lipohypertrophy [Lipohypertrophy refers to the thickening or lumping of fatty tissue under the skin caused by repeated injections into the same site, which can reduce the effectiveness of insulin absorption].

Insulin was administered close to the prescribed time and dated on opening. Medicines used to manage Parkinson’s symptoms were also administered at consistent times, which is essential for effective symptom control, and records confirmed good adherence.

Controlled drugs (CDs) were stored securely, with accurate CD registers, double‑signature checks, and documented destruction of discontinued items. The clinical lead completed a six‑weekly medicines audit, supplemented by monthly audits from a clinical lead in a sister service and regular PRN medication audits.

Where medicine errors had occurred, these had been investigated promptly. Records showed that learning outcomes were documented, and staff involved received competency assessments and refresher training.

People and their relatives told us they had no concerns regarding medicines administration, and feedback indicated confidence in how medicines were managed within the home.