Highmarket House

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.

The service was in breach of legal regulations in relation to people’s safe care and treatment and staffing.

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 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.

The provider reviewed incidents and accidents and ensured that any learning from them was shared with staff. Staff told us they would report incidents and accidents and that they were appropriately investigated. Lessons learnt were communicated to staff via handovers, staff meetings and incident bulletins.

Incidents and accident logs were reviewed by the registered manager in order that any themes could be identified. A monthly falls analysis was carried out to look for trends and themes. Relatives told us they were informed if an incident had occurred such as a fall.

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.

People had access to external healthcare professionals when needed. Staff supported people with attending healthcare appointments. Relatives told us they were kept up to date with people’s referrals and appointments. One person told us, “They made an appointment for me to have my ears syringed four weeks ago.”

Systems were in place to ensure information was available for staff to send with people when they were admitted to hospital.

People were protected from abuse. The Provider had systems in place to ensure staff received training on how to identify and report abuse. People and their relatives told us they were safe at Highmarket House. One relative told us “Yes, I definitely feel that [person] is safe, very much so, the care is good, everyone there is helpful, and they are good at what they do.”

Staff demonstrated a good understanding of how to safeguard people from abuse. Staff told us they would not hesitate to raise concerns to the registered manager, and to external parties if needed.

We observed staff supported people in a safe way, for instance when people were being supported to move positions, this was completed in a dignified manner.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). We observed some people had restrictions placed on their movement. Where restrictions were in place, these were lawful. For instance, bed rails or lap belts on wheelchairs. We found some improvements were required on how records were completed for decisions about mental capacity and best interest. We have provided this feedback to the registered manager. We found people and staff had access to information about how to raise safeguarding concerns.

There were systems, processes, and practices to make sure people were protected from abuse and neglect. Records showed the registered manager and provider monitored events like falls and unexplained bruising, to ensure any patterns of concern were identified.

People were not routinely and consistently protected from exposed risks. We found improvements were required to ensure all risks posed to people were identified and mitigated.

We found mixed practice about how the provider and registered manager identified and mitigated risks to people. People who were at risk of sore skin and dehydration were placed at a greater risk of deterioration in their health. For example, care plans were not routinely clear on how often people needed support to reposition to reduce the risk of sore skin. Where care plans did identify time frames, records did not always show this was provided. People had routinely been given a fluid target of 1600mls to reach each day. This was not personalised to each person’s health condition and records did not routinely demonstrate people were offered or consumed the target level. This placed people at greater risk of dehydration. We discussed this with the registered manager and provider who advised they would take action to ensure fluid targets were reviewed and systems would be put into place to monitor fluid intake.

However, records showed other risks posed to people as a result of their medical conditions were assessed and mitigated. People had risk assessments in place for falls, moving position and choking as examples. Each person’s risk assessment was reviewed monthly. The registered manager confirmed if a person fell, a falls risk assessment should be updated. We found this was the case.

People were not routinely and consistently protected from risks associated with the environment.

People were at risk of scalding from hot food trolleys. We observed people were left unattended in kitchen and dining areas with a hot food trolley. One person was observed to be using the hot surface as support as they walked around. No risk assessment was in place at the time. We discussed this with the registered manager who stated they would expect staff to be present when the food trolley was in use and hot. However, we observed this was not always the case. After our feedback the registered manager completed a risk assessment and reminded staff to remain in the area. However, people were placed at risk prior to our feedback.

People had free access to items which could cause harm. We found a razor in an unlocked cupboard, and aerosols were readily available for people living with dementia, which had the potential to be ingested and cause harm.

The building is a purpose-built care home and was well-kept. It had been designed with wide corridors to accommodate wheelchairs and equipment. All rooms were single and had en-suites. Adapted bathrooms were provided. There was level access throughout, including garden areas. Window restrictors had been fitted.

There were a range of areas people could make use of, including lounges, quiet areas, a bistro area, cinema room, hobby room, hairdressing salon and gym/movement room. Dining areas were set throughout the home with tablecloths, and napkins. There was no clutter or obstructions around the building. Fire exits and escape routes were clear.

A range of health and safety checks were undertaken incorporating fire, gas and water safety. The home was kept in good order by a maintenance manager and external contractors. Emergency evacuation plans had been written for each person, which outlined support they would need. An emergency grab bag, business continuity plan and other documents were readily available, in case the premises needed to be evacuated.

Fire drills had been carried out regularly and these included all staff. Equipment to assist people with moving had been serviced and was safe to use.

People were not routinely supported by sufficient numbers of staff who had been deployed to ensure their needs were always met in a timely manner.

We observed occasions when people were left unattended in areas where they were exposed to risks. We observed people being supported with personal care outside of their desired timeframe. For instance, a person’s care plan stated they liked to get up between 8 am and 9 am. However, we saw they were not supported to get up till after 10.30am.

People and their relatives gave mixed feedback about staffing levels. People told us about the impact when staff were not available to help. One person told us they were often told by staff “I can’t come yet, I have got to help with other people first,” when they are asking staff for support. Another person told us “Some of my medication should be given at 8 o’clock but sometimes I don’t get them until noon and that is no good, sometimes I am going out and once I couldn’t go because I hadn’t had my tablets”. Other feedback we received from a person about staffing included, “There should be 3 [staff] on each unit but often there are only 2 and they [staff] struggle, sometimes they [staff] might send someone to help between 2pm and 8pm but it is a struggle for the 2 of them”, “I think there are too few staff on duty at weekends, there are 2 carers on each floor then and one who finishes at 14:00 but those 2 have to do all the personal care and are often called off to help other incidents”, “Numbers vary to be honest…, we always make sure a carer is sitting with him when we leave but sometimes it is difficult for us to find any carer to go and sit with him” and “Sometimes when I am there I don’t see any carers, like this morning when I visited I didn’t see anyone at all”.

However, we received comments from people who expressed satisfaction about staffing levels. Comments included, “It seems like there are enough staff, I visit at all different times but generally there seem to be enough”, “They [staff] keep coming in all the time and say, ‘are you alright [name of person] and asking me if I want anything”, “I don’t feel there are either too many or too few carers”.

The registered manager and provider had systems in place to assess people’s dependency and the required staffing levels. This took into account a number of factors which people needed support with. However, the system did not always accurately reflect people’s needs. Staff told us they felt the dependency calculation was not robust enough to identify required staffing levels. We have provided this feedback to the registered manager and provider.

People were supported by staff who had been safely recruited. This included a check for any criminal convictions, gaps in their employment history and uptake of references. Where staff were required to have a nursing qualification and registered with the associated regulator, checks were carried out to ensure staff had a license to practice as a nurse. Staff told us they had opportunities to have one to one meetings with a line manager and had access to training to ensure their skills and knowledge was updated.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We observed, people were not offered hand cleaning prior to their meal. We asked a member of staff if they had wipes for people to use and they told us they did not. We have provided this feedback to the provider. They told us hand sanitisers were available on entrance to dining areas, however, on the second day we visited the home, more than half of the hand sanitiser stations were not working or empty.

Systems were not effective to ensure food items were safe to eat. We found fridges were not maintained in a safe way, they were in need of cleaning and defrosting. We found food items were not in date or not dated when opened to ensure they were used prior to expiry date. We provided this feedback to the registered manager. The systems in place to record checks on fridges and food items were not being completed routinely. We found there was little oversight of this to ensure remedial action was taken.

We found 1 member of staff who told us they had provided personal care to a person, was not observing good hand hygiene. They told us the provider’s policies stated they could wear nail varnish. However, when we checked this was not the case.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacity and preferences.

There were 4 medicine rooms across the home however they did not have the same processes running throughout. In 1 of the rooms, we observed paperwork stored in an untidy pile on the side of the medicine’s fridge, which did not support effective record-keeping. The support document for homely remedies signed by staff was out of date by 7 months. Additionally, the homely remedy authorisation form for people in 1 room was out of date by 1 year.

Medicines and Healthcare Regulatory Agency [MHRA] medicines alerts and safety information were stored inconsistently across the different medicine rooms. Records to monitor the accuracy of a glucose meter for a person with diabetes could only be located for 1 month. This meant we could not be assured this was being consistently completed. Stock balances of medicines were recorded, however this was done differently over the 3 floors in the home, some were done daily and some weekly. On 1 floor, weekly stock counts were being done monthly. Staff when questioned gave different responses for the frequency of when it should be done. Gaps were noted in daily stock counts for numerous people across the home. This meant there was a lack of clear guidance and oversight in medicines management across the 4 medicine rooms, which increased the risk of stock errors going unnoticed.

Medicines that needed refrigeration had records available of current, maximum and minimum temperatures monitored daily to ensure the medicines were stored safely. However, in 1 medicine room, we saw records for a period of 1 month where the records for fridge temperatures were not clear and missing entries.

Medicines were stored securely in locked cupboards. There were systems and processes in place to ensure the safe administration of medicines. This was recorded on people’s electronic medicines administration record (eMAR). People’s allergies were accurately recorded and eMAR had up-to-date photos of people in the service. Preferences about how people wanted their medicines given were present in records.

When required medicines (PRN) protocols were in place, we saw examples where they did not always include all the necessary detail to be person centred. This lack of detail increased the risk of inconsistent care and may make it difficult for staff to make informed decisions. Where variable doses were prescribed, there was often no clear instruction on what dose to administer.

Care plans were seen to be person-centred and included information on people’s prescribed medicines. They contained enough information to allow staff to manage people with complex medical conditions such as diabetes. However, we saw an example where the units of insulin to be given in the care plan did not match the eMAR. This had not been identified by the service, even though the person’s care plan had been recently reviewed. This was corrected on the day of the inspection. Records of people’s blood sugars were not always clear and consistent. Some staff recorded them in administration notes, and some did it correctly under the blood sugar records for the person.

A person was discharged from the hospital and prescribed a medicine that they had an allergy to, this allergy was recorded in the care home care plan and eMAR. This did not prompt a review of records with clear notes of actions taken. In addition, a new allergy was noted on the discharge paperwork, but the staff had not updated this on the care home records. This was raised on the day of the inspection and records were corrected.

A person’s care plan indicated medicines were to be given covertly [disguised in food or drink] however, the person was taking their medicines orally. This was not documented in the care plan to allow for a review of covert administration of the medicine, if suitable. Best interest meeting information was present however; the GP and pharmacist were not named on this form. This meant the record had not been completed with all information and this was not noticed during audits.

Controlled drugs [CDs] were stored securely in line with legislation and policy. CD stock checks were carried out as per the provider’s policy.Staff were caring and considerate when administering medicines. Staff had received medicines training, and their competency was assessed.