Harborne Lane Nursing Home

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 a risk that people could be harmed.

Risk assessments and care plans did not always contain sufficient, up to date information to keep people safe. Safeguarding referrals were not always made when there were concerns about potential abuse or neglect. Improvements were required to ensure accidents, incidents and allegations of abuse were clearly documented, reviewed, investigated, and analysed to identify trends and reduce the risk of them happening again. Lessons learned were not always shared with staff. Improvements were needed to medicine management. Some covert medicine plans did not follow NICE guidance or evidence the Mental Capacity Act 2005 had been followed. We observed the medicines trolley was not always locked when it was left unattended while staff administered medicines in service user’s bedrooms.

This left people at risk of avoidable harm and was a breach of regulation 12 safe care and treatment.

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.

Systems were in place to report, record and monitor incidents and accidents. However, further improvement was required. Accident and incident records did not always evidence actions that had been taken to reduce the risk of reoccurrence. One person had an unwitnessed fall and sustained a head injury. Care staff had noted it was not safe for the person when they walked over their sensor mat. There was no evidence this had been reviewed or alternative options considered to reduce the risk of falls and injury.

People told us they knew how to raise concerns and felt confident if they had concerns, they would be listened to. One person told us, “We have a new manager [The registered manager] they are approachable and will listen to any concerns.” Relatives told us they knew how to make a complaint or raise a concern.

The provider had processes to monitor safe systems, pathways and transitions. However, improvements were needed to ensure pre assessments carried out prior to people receiving care were robust to ensure accurate risk assessments and care planning. One person, who had lived at the service for several months, had an autoimmune condition. Records contained no information about the support this person needed to manage the condition safely, or current information about risks and symptoms. There was no information about external health professionals involved in the person’s care and treatment. The provider recently referred this person to the hospital for a review, but the delay in this referral exposed this person to the risk of not receiving appropriate care or treatment.

Relatives told us they were involved in regular reviews of their loved one’s care. There was some evidence people had contributed to the development of their care plans.

Staff told us they ensured people were involved in discussions about their care needs and followed their care plans and risk assessments. One staff member told us, “I will talk to people and their relatives to get to know their preferences. It is also recorded on the person’s care plan.”

Systems were in place for safeguarding concerns to be shared with the local authority safeguarding team and other appropriate agencies. However, improvements were required to ensure all required action was taken to ensure people were protected from abuse and neglect. One person was admitted to hospital and returned to the home with an injury. The provider had not sent a safeguarding alert regarding the hospital discharging a patient with an unexplained injury. In response our assessment the provider submitted a safeguarding referral. People told us they felt safe living at the home. One person said, “I feel safe here.” Another said, “I’m absolutely safe here.” Staff described their responsibilities in relation to safeguarding and told us how they would report any concerns to the relevant agencies as required. Staff told us they had completed safeguarding training and were aware of the different types of abuse and reporting procedures to follow if they had any concerns of abuse. One member of staff said, “There are different types of abuse such as physical, emotional and financial”. Another staff member told us, “If I witnessed abuse, I would first make sure the person was safe. I would report the incident to my manager. If I was unhappy with how the incident was managed, I would contact the safeguarding local authority, the Police and CQC”

Systems were not effective to ensure risks to people’s health and safety were assessed and managed. One person had epilepsy, diabetes and hypertension. There were no care plans to support the management of risks related to those health conditions. Choking risk assessments and care plans did not always provide staff with clear instructions on how to manage the risk of choking. One person, was identified as high risk following a choking incident and referred to Speech and Language Therapists. However, there was no interim guidance or instructions for staff to follow to support the person safely to minimise the risk of choking and no interim advice had been sought pending input from Speech and Language Therapists to minimise the risk of choking.

People and relatives told us staff understood their needs and provided the support they needed to stay safe from harm. A relative said, “[Name of service user] gets on with all the staff. Everyone tells me that they are a right character. I am really pleased to see and hear this.”

Risks were not always managed effectively. One person posed a risk to other people and compromised their dignity and safety. The person’s risk assessment lacked sufficient information about this risk and how it was managed. It contained no information about patterns or triggers for staff to be aware of and no details of strategies to keep the person engaged and occupied in meaningful activity to minimise the risk.

Seizures were not recorded or monitored. One person at risk of seizures had no record of the seizures they had had since admission. There was no evidence of medical reviews or observation following a seizure. Seizure monitoring is important because it can assist health professionals to identify triggers to be avoided and help reduce the number of seizures. It can also help professionals determine the most appropriate treatment for service users.

People and relatives told us they felt the environment of the home was managed safely. One relative told us, “The home is immaculately clean.” One person said, “The home is well cared for.”

Staff told us they felt the presentation of the home was good. Staff also told us they felt confident to respond in the event of a fire emergency and had participated in drills and training. This included night staff who had also practiced fire drills.

During our visits we saw the home was uncluttered and well maintained. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and relatives told us they thought there were enough staff to support their needs. One person told us, “I think that there is enough staff”.

We observed enough staff to support people. One staff member told us, “There are enough staff on duty, you don’t feel rushed all the time”.

Staff received an induction and regular training which included mandatory training. A staff member told us, “During my induction, I shadowed an experienced team member, and I also completed training. After my induction, I felt comfortable to support people on my own, and I was given the option of extending my induction if I needed to”. Supervision and appraisals were in place to monitor performance and development. Staff participated in monthly staff meetings where they were able to share information and receive important updates about the service.

The service ensured staff had the knowledge and skills required to meet people’s needs. The provider followed safe recruitment practices and had ensured appropriate pre-employment checks were completed satisfactorily before staff were employed. During visits we saw generally the staff team were relaxed and conversational and not rushing around with a task-based focus.

People and relatives told us they we happy with the cleanliness of the home and the support they received with personal hygiene. One person told us, “The home is lovely and clean.” Staff told us they received training in infection prevention and control and were aware of safe hygiene practices. No concerns were raised about the availability of Personal Protective Equipment (PPE). The provider had effective policies and procedures in place regarding infection prevention and control. The provider knew how to respond to risks and signs of infection and how to make sure infection outbreaks at the service would be effectively prevented or managed. The home was clean and well maintained including shared areas and people’s bedrooms. Staff wore PPE (personal protective equipment) and understood infection prevention procedures which they followed to protect people from the risks of infection. The service assessed and managed the risk of infection appropriately.

Improvements were needed to ensure medicines were consistently managed safely. The service did not ensure its policy for safe storage of medicines was followed. We observed the ground floor cupboards containing medicines were not locked. On floor two, cupboards containing medicines did not have locks.

The medicines trolley was not always locked when it was left unattended while staff administered medicines in people’s bedrooms. This placed people at risk from being able to access these medicines.

People and their relatives told us they received their medicines as prescribed. One person said, “My medicine is done on time.” A relative said, “They are very careful with the medication and the drugs.” However, our assessment found the management, storage and administration of medicines did not always meet the expected standards.

One person was prescribed time-sensitive medicine. Medicine records did not specify the medicine was time sensitive or the times the medicine had to be administered. This meant staff, not familiar with the service user, would not understand the importance of giving the medicine on time. The care plan did not reference the exact times the medicine had been prescribed and was being administered alongside the home’s medicine rounds. We could therefore not be assured the medicine was administered as prescribed.

Two people receiving covert medicine did not have the sufficient documentation in place. Covert medicine plans did not evidence that NICE guidelines or the Mental Capacity Act 2005 were followed. Pharmacy input had not been obtained and is required for each medicine to ensure it is administered safely. There was no evidence of best interest meetings to ensure the decision to administer covert medicine was in the person’s best interests.

Staff informed us they received training in the safe handling of medicines and had their competencies checked on a regular basis.