Henwick 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. At our last Inspection we rated this key question good. At this Inspection the rating has changed 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 safety of the environment.

This service scored 56 (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 in respect of incidents and accidents. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt and shared with staff to identify good practice. Accidents and incidents were reported to the relevant external agencies, reviewed and followed up by the registered manager. The leadership team completed monthly accident and incident analysis, this helped staff to identify themes and trends for people who had falls, distressed behaviour, medication errors, and accidents. Staff told us they were kept informed of accidents and incidents through staff meetings, supervisions and documentation. One staff member told us, “There is a process for accidents and incidents that we can refer to and learn when things go wrong. We have team meetings where things are discussed we also can make suggestions to ensure people are well cared for”.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. However, feedback from healthcare professionals suggested compatibility with other people was not always considered. The provider completed pre assessments to gather information before a person moved into the service. People’s care plans demonstrated they were supported to access healthcare when needed. Staff and leaders worked collaboratively with external health care professionals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately. The majority of people and relatives told us they felt safe, one person told us, “I am safe, yes, it’s the people around me which assures me”. Staff had received training in safeguarding and vulnerable adults and understood their roles and responsibilities to keep people safe. Staff told us should they raise any concerns these would be listened to and acted upon by the management team. One staff member told us, " I would report concerns to management, if no action was taken, I would report to the local authority, the police if necessary, and I would make sure that the person is safe”.

The provider did not always work well with people to understand and manage risks. Feedback from people and relatives in relation to being involved in managing risks and care planning was inconsistent. Some people were supported to take risks and access the community unsupported with the relevant risk assessments in place. However, there was a consistent theme of feedback where people and relatives told us they had not been part of care planning or reviews, and some people told us they did not know what was in their care plan. People and relatives told us, “I’ve never heard of a care plan. No official reviews as such” and “I’ve never been involved with a review, I’ve heard of care plans, but I haven’t seen one”. We shared this with the registered manager who told us they would start to make changes to ensure people and relatives became part of the care planning process.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and environment supported the delivery of safe care. During our visit we identified multiple environmental risks. All areas of the service had exposed piping which could potentially cause harm and scalding to people living at the service. There was open access to external sheds, storage rooms and the laundry which stored harmful chemical products, which could have potentially been accessed by people living at the service. We identified 2 uneven drain covers on the ground floor of the building. One drain cover had broken edges and was unstable when walked on, this posed a potential trip and falls risk for people and staff. Some fire doors closures were not working correctly and had been propped open with furniture; this posed a fire safety risk. There were multiple areas of the home where we identified broken tiles and chipped walls posing a risk of potential injury to people. The registered manager and leadership team were receptive and responsive to our findings and took action to address some of the concerns identified, this included devising an action and refurbishment plan for some environmental work which may take a longer time to complete.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, not all recruitment files we checked obtained full staff employment histories which represented a gap in the recruitment process. The oversight could impact on the ability to fully assess the staff members suitability and experience for their job role. We received mixed views from people and relatives regarding the staffing levels, some people told us they thought there were enough staff, whilst others said they thought the service was short staffed. The service had recruitment processes in place. These included references and Disclosure and Barring Service checks (DBS). A DBS is a criminal record check to ensure the staff member is of good character to work with people at the service.

The provider did not always assess or manage the risk of infection. Not all areas of the home were maintained in a way which safely supported effective infection prevention and control practices. For example, we saw faeces on equipment in bathrooms, unclean walls, doors, floors, tables and equipment. There were multiple areas of the home where skirting boards and walls were either chipped or broken away, and this posed a risk with maintaining infection prevention. This was shared with the registered manager and senior leadership team. On the 2nd day of our visit Infection Prevention and Control (IPC) had improved, there were 7 domestic staff carrying out a deep clean of the building. We visited on a 3rd day where we saw improved IPC measures had been maintained. The service had a policy and procedure in place for Infection Prevention and Control. There were regular audits completed by staff. However, these audits were ineffective as they had not identified the concerns we found during our inspection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found prescribed creams were not stored safely throughout the building and did not have open dates. This meant people were at risk of harm from accessing prescribed topical medicines. Application charts lacked detail of where and how much prescribed creams to apply to people, which meant they may be ineffective or applied incorrectly. ‘As and when’ medicines were not always given as prescribed or within the recommended timescales. This meant people were at risk of medicines not being effective or people being over and under medicated. The services medicines policy was missing some important information and required a review and updating. Staff had completed medicines training and had their competency assessed. We shared our findings with the registered manager and leadership team who started to take action during the inspection process.