Huntingdon Court

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.

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 was in the process of developing a more positive approach to learning within the service, which included the development of a culture based on openness and willingness to learn. Processes to ensure robust analysis of incidents to ensure lessons were learnt and shared were not fully effective. For example, incidents and accidents were reported. However, records around incidents where people had become distressed were not completed accurately or fully. These did not provide effective oversight and ensure lessons were learnt to embed good practice. We discussed this with the registered manager during the inspection, and they told us they would review the process. Improvements had been made to support better oversight of pressure wounds and specific healthcare needs overall, though some health professionals felt further improvements were needed to ensure lessons learnt were fully embedded in staff working practices.

The provider was making improvements in how they worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The registered manager was developing relationships with healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, these improvements were only recently introduced so we could not be assured the improved systems had been fully embedded. People had been seen by health professionals when required. For example, records showed people were reviewed by a speech and language therapist (SALT) if staff noted swallowing concerns. Staff provided information to other agencies, for example when people were admitted to hospital, to support a safe transition. Health professionals provided mixed feedback about their experience in working with the service in providing safe care. A health professional told us they had no concerns and felt staff shared information well during visits and by telephone. Two health professionals felt staff did not always listen or act on advice given during visits. Comments included, “I felt [Name] was low in mood and needed extra support. When I suggested this to the management team, it wasn’t well received, and nothing has been done” and “I think staff could work with agencies better in managing pressure wounds.” The registered manager was able to provide evidence and information that concerns had been acted on, though acknowledged communication with health agencies required development at the time of our assessment.

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. People told us they felt safe. A person told us, “There’s always someone at night who puts their head in and says, ‘are you alright?” Staff had been trained and understood their responsibilities to keep people safe from avoidable harm and abuse. One staff member said, “I have done safeguarding training. I would report concerns to the senior on the floor. I am confident it would be dealt with.” There was a safeguarding and whistleblowing policy in place. We saw they worked openly with the local authority and safeguarding team where any concerns had been raised. A visiting health professional told us, “I have been coming to the home regularly for a few years. I have never witnessed any major worry. Staff are always willing to assist, meet with me on arrival and discuss concerns on the telephone.” When conditions were imposed as part of a legal authorisation to restrict a person of their liberty, records showed there was clear guidance in people’s care plans to inform staff how to ensure conditions were met.

The provider did not always ensure people’s care records included information on how staff should mitigate risks to people that were identified in risk assessments.Potential risks to people’s health and welfare had been assessed and risk assessments had been reviewed regularly. However, when risks had been identified, care plans did not always inform staff how to reduce the risks of harm to people. For example, where people became distressed, there were positive behaviour support strategies in place. However, strategies did not specify what distraction techniques staff should use to reduce the person’s distress. Additionally, strategies referred to staff removing a person from an area to a quieter place when they were in crisis. Strategies did not provide guidance as to how staff should do this to keep the person and others safe from harm. People had detailed personal evacuation plans to enable staff to support them safely in an emergency. However, some plans contradicted information in people’s mobility risk assessments. For example, a person’s evacuation plan referred to them using a hoist, but this was not included in their mobility risk assessment. The registered manager told us they would develop records following our inspection visit. We saw room temperatures were very high on the day of our inspection visit. Although staff were supporting people to keep hydrated, they had not evaluated environmental risks associated with heatwaves and were not consistently following government heatwave guidance. For example, people were sat in direct sunlight in communal areas as windows did not have any coverings to protect them. We saw people were hot and uncomfortable. We raised this as a concern with the registered manager who arranged for temporary window coverings and for portable fans to be purchased and installed during our inspection visit. We saw staff supported people to transfer safely using hoisting equipment. However, we also saw a staff member support a person to sit using a potentially unsafe approach. We raised this with the registered manager who acted on our concerns by ensuring all staff had refresher moving and handling training and increasing spot checks of staff working practices.

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. Some areas of the premises were worn and required attention. Several internal doors did not close correctly into their rebates. These were fire doors and presented a risk of poor containment and protection in the event of a fire. A person told us, “My door doesn’t work effectively as a fire door. It won’t close automatically if there is a fire. I asked for it to be fixed. The maintenance guy says he’s ordered new batteries, but that was weeks ago.” We raised these concerns with the registered manager. A maintenance man attended whilst we were on site to address the urgent concerns around fire doors. We reviewed the providers improvement plan records and found some maintenance issues rated as high in January 2025 had not been completed or remained in progress. These included windows that did not open and radiators that did not work. The front grounds to the service were unkempt and overgrown and the rear gardens were also overgrown, cluttered and unkempt. This made it difficult for people to access and were not areas people could sit and enjoy or spend time in. Following our inspection, the registered manager liaised with people’s relatives who donated their time to clearing and tidying the grounds. Some areas of the service had been redecorated, but many areas appeared worn and tired. The provider’s representatives acknowledged there had been a gap between operations and maintenance. They had worked to resolve this through new appointments and were confident this would result in improved estate management and oversight.

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. There were enough staff to ensure people’s safety and needs were met. The service used a dependency tool to calculate staffing requirements. People felt there were enough staff deployed, though told us they sometimes had to wait for help and staff were always busy. Relatives felt their family members had to wait too long on occasions. A relative told us, “There are not enough staff, they are very busy.” We observed staff were continually busy but were responsive if people needed support or asked for assistance. Staff told us they had no concerns about staffing levels. A staff member told us, “I think there are enough staff to look after people. All residents are looked after very well.” The provider followed safe recruitment procedures to ensure staff were safe and suitable to work in the service. We found risk assessments to support staff with specific needs or health conditions were not routinely undertaken. This is important to ensure staff have the support they require and to ensure any reasonable adjustments are made. The registered manager told us they would raise this with the provider.

The provider assessed the risk of infection, though improvements were needed in responding to potential risks for the spread of infection. Some toilets and bathrooms were in need of decoration to address potential risks of infection from exposed porous wood, breaks in flooring and missing tiles. Areas of the service had malodours that were present throughout our inspection visit and some chairs and carpets were heavily stained. The provider’s representatives acknowledged some areas of the service required update and redecoration. The registered manager told us carpets had been deep cleaned following our inspection visit. We observed staff following safe practices when wearing and disposing of personal protective equipment, including gloves and aprons, which were readily available. Laundry procedures and kitchen hygiene were safe and well managed.

The provider did not always make sure medicines and treatments were safe and met people’s needs. Body maps to record position of transdermal patch applications were not consistently completed by staff. There was a lack of correlation between changes in people’s blood sugar readings and the administration of fast acting diabetic medication. This meant we could not be assured staff were responding to changes in line with people’s protocols. We found numerous gaps in signatures on medicine administration records and lack of consistency in dating medicines with a limited expiry date once opened, including eye drops. We raised this with the registered manager who ensured staff received refresher training in diabetes awareness and implemented more robust oversight of medicines following our inspection visit. Medicines were stored safely and when no longer required, were disposed of safely. Staff who administered medicines had received up to date medicine training and had their competencies checked. People had no concerns about their medicines. Comments included, “They are very good at giving out medication” and, “If I am going out, the staff always make sure I have had my medication.” A third person described how they had requested information about their medication and the senior staff member had arranged to go through it with them.