HF Trust - Pound Lane

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 53 (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, investigate or report safety concerns effectively, and lessons were not always learned or embedded to improve practice. Although incidents, including medicines errors, safeguarding concerns and accidents, were reviewed and actions taken, such as additional training, competency assessments, increased auditing and enhanced oversight, similar incidents continued to occur.

This indicated learning was not yet consistently embedded into practice. Monthly incident analysis reports supported reflection and learning, with the interim service manager recognising the importance of maintaining "a strong culture of accountability, adherence to policies, robust supervision, and continuous monitoring to ensure safe, effective and person-centred care." Leaders demonstrated a commitment to improvement; however, further work was needed to ensure actions resulted in sustained improvements and a reduction in recurring incidents.

People were generally supported to access healthcare services and specialist professionals when required, including GPs, neurologists, psychiatrists, speech and language therapists (SALT), and falls services. Records showed people attended routine health appointments and received timely referrals when changes in need were identified. The provider also worked with partner agencies to support planned transitions. For example, one person with dementia was being supported to explore a more suitable placement, with family members involved in planning for future moves. Relatives described positive experiences of transitions; one relative told us their family member had been supported when a long-term housemate moved to an older person's service and was able to maintain contact with their friend.

However, the provider did not always work effectively with people and healthcare professionals to ensure information about risks and support needs was consistently reflected across records. For example, one person's emergency fact sheet did not identify their risk of choking despite a recent choking incident and SALT guidance being in place. Another person's hospital passport identified a choking risk but did not include their current IDDSI dietary level. (IDDSI is a universal scoring system used to describe how thick a drink is or how soft a food is so that people with swallowing difficulties can eat and drink safely). This meant important information may not always have been readily available to healthcare professionals or unfamiliar staff involved in people's care, creating a risk that support would not be delivered consistently.

The provider did not always work effectively with people and partner agencies to ensure people were protected from abuse, avoidable harm and neglect. Systems were in place to identify, investigate and respond to safeguarding concerns, and staff demonstrated an understanding of their safeguarding responsibilities. One staff member told us, “I would immediately report it to my manager and senior and senior on call” if they suspected abuse. Relatives generally told us they felt their family members were safe and that concerns were acted upon appropriately when identified. Safeguarding concerns were reported to the local authority where required and investigations identified actions to reduce the risk of recurrence. However, safeguarding systems were not always fully effective.

We identified one safeguarding-related incident that met the threshold for notification to CQC but had not been submitted; the interim manager took immediate action and submitted the notification retrospectively. In addition, a number of medicines-related safeguarding concerns continued to occur despite learning and actions being implemented. This demonstrated that whilst leaders were responsive when issues were identified, learning was not yet consistently embedded and concerns were not always shared promptly or appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider maintained a tracker to monitor DoLS applications, authorisations and any conditions attached to them. We identified several DoLS authorisations recorded as expired on the tracker. The provider had recognised the need to review and update its oversight arrangements in line with current guidance and legislative changes and was undertaking a review of authorisations and associated conditions to strengthen assurance and monitoring processes.

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.

Staff worked with people and those important to them to understand and manage risks in a way that promoted independence and choice. Care plans and risk assessments generally reflected people's preferences and identified measures to reduce risks associated with falls, epilepsy, choking, mobility and behaviour whilst supporting people to maintain meaningful lives. There was evidence of relatives being involved in decision-making, best interest processes and reviewing care arrangements. One relative told us, “They are on top of the problems," when describing how staff responded to concerns relating to falls and safety.

Another staff member described supporting people to maintain independence by helping them select the correct money in advance so they could pay for items themselves when shopping.

However, information used to manage risks was not always consistent across records. For example, one person's emergency fact sheet (quick-reference summary of vital personal and medical details used when a person with a learning disability needs urgent or hospital care) stated they did not have dementia despite a dementia diagnosis, dementia support plan and dementia risk assessment being in place. In another example, a person's emergency fact sheet did not include information about their choking risk despite a recent choking incident, SALT guidance and choking risk assessments being recorded elsewhere within their care records. Following the assessment, the interim manager reviewed and updated all people's emergency fact sheets to improve the accuracy and accessibility of risk information.

Whilst the provider detected and controlled potential risks in the care environment not all equipment, facilities and technology supported the delivery of safe care.

People lived in environments that were generally clean, comfortable and adapted to meet their individual needs. Environmental risk assessments and regular health and safety checks were completed, and adaptations such as sensor mats, padded furniture, bed alarms and specialist equipment were used to help people remain safe whilst promoting their independence. Relatives spoke positively about the environment, with one telling us, “The place is clean and tidy." Staff demonstrated an awareness of their responsibilities for maintaining a safe environment and described the range of safety checks they completed. However, some environmental issues were identified during the assessment, including worn furnishings, damaged curtains and areas of the premises requiring refurbishment. Staff also acknowledged that parts of the environment were tired. The provider had recognised these issues and developed a maintenance plan to support ongoing improvements.

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.

Staff had been recruited safely, and recruitment records contained the necessary pre-employment checks, including Disclosure and Barring Service (DBS) checks and employment references. There were generally enough staff deployed to meet people's needs and support them to access activities and maintain their routines. Induction, training and competency assessment processes were in place, and staff told us they received shadowing opportunities and were observed before undertaking responsibilities such as medicines administration. One staff member said, “I feel I am always supported by my work colleagues, and I feel like my seniors and managers listen if I am concerned or need advice or assistance." However, staff and managers acknowledged ongoing vacancies and staffing pressures at times, resulting in the use of agency staff. Whilst agency staff were described as generally consistent and familiar with people's needs, we received mixed feedback about staffing levels and practical training, indicating further work was needed to ensure all staff received the support, supervision and competency-based training required to carry out their roles safely and effectively.

The provider had systems in place to prevent and control the risk of infection. The service was visibly clean and tidy during the assessment, and staff completed regular cleaning and environmental checks. Staff were knowledgeable about their responsibilities and described using cleaning schedules, infection control procedures and secure storage of cleaning products. One staff member told us, “We have a checklist of all of our cleaning tasks that must be completed every shift." Staff also explained that COSHH cupboards were locked and contained the cleaning supplies required to maintain hygiene standards. We received no concerns from relatives regarding infection prevention and control practices, and feedback indicated people were supported in a clean and hygienic environment. Whilst infection prevention and control arrangements were generally effective, some areas of the environment were tired and required refurbishment, and the provider had developed a maintenance plan to support ongoing improvements and ensure standards were consistently maintained.

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

People generally received their medicines as prescribed, and systems were in place for the storage, administration and auditing of medicines. Staff responsible for administering medicines had completed training and competency assessments, and medicines incidents were investigated and reviewed to identify learning. Following medicines incidents, the provider took action, including staff retraining, competency reassessments and increased management oversight. We identified some gaps in medicines management, including stock control processes, medicines auditing and PRN protocols (medicines taken as required) that required review. The interim manager took prompt action during the assessment and submitted updated PRN protocols to the GP for review and authorisation. Whilst leaders demonstrated openness to learning and responding to concerns, medicines-related incidents continued to occur, indicating improvements had not yet been consistently embedded into practice.