Havengore House Residential Care 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 as Good. At this assessment the rating has remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

There were multiple robust systems in place to monitor and improve when lessons were learnt. The service held “daily flash meetings.” Items discussed included resident of the day, where care plans were spot checked for a specific resident. Other topics discussed and looked at included housekeeping, catering, maintenance, administration, wellbeing (including staff), feedback from management on their audits and spot checks. This allowed good oversight and resulted in a proactive management team that knew their service.

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.

Prior to people moving into the service, a pre-admission assessment was carried out to ensure the service could meet people’s needs. The registered manager effectively shared information when people were admitted to hospital or required care at home after leaving the service.

A health professional who often worked with the service supporting people with rehabilitation told us “Management are quite responsive on obtaining records that are needed. Very responsive, within 48 hours and I have time critical things I need. They are very responsive in working with me.” They added “If I hear my patient is coming to Havengore I don’t have to worry.”

A relative of a person who uses the service told us, “We had to move [relative] from [another provision]18 months ago. It was a difficult time and Havengore were brilliant in supporting us and getting [Relative] settled in.”

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.

There were effective systems in place to manage safeguarding concerns, the provider kept and maintained a safeguarding log, clear lines of investigation and follow up were recorded and evidenced. Responses to risks were dealt with in a timely way, for example a lady had an unwitnessed fall one evening, on the day of the fall care plans and risk assessments were updated. Relevant referrals were made to the local authority and CQC as well as health professionals, lessons were learnt and shared with the team.

Staff were able to give good accounts of their safeguarding duties, signs of abuse to be aware of and how to report this appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider could evidence that discussions were held with individuals and family members in relation to care and managing risks, good principles of the Mental Capacity Act 2005 (MCA) were followed. Regardless of diagnosed conditions efforts were made to gather people’s views in how their risks should be managed.

A relative of a person using the service told us, “We’ve been involved with [relative]care plan; [relative] has an end of life plan in place; we asked them to include checking [relative] eyes as part of [relative] care plan which they are doing…We can ring up at any time to get an update on [relative] and if there’s any problem, they’ll ring me and give me an update”.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff had good knowledge of fire safety procedures, and every person had a personal emergency evacuation plan (PEEP). The purpose of a PEEP is to ensure that all people can evacuate the building safely and promptly in the event of an emergency. Reminders of these were also present at every single designated fire exit.

Equipment was available and maintained to meet people’s needs. We saw evidence fire equipment, lifting equipment and electrical safety checks were completed as required by regulations such as Lifting Operations and Lifting Equipment Regulations 1998 (LOLER).

There were also health and safety/maintenance audits in place, these were regularly reviewed and updated, and the inspection team saw evidence of these being updated as needed.

A relative of a person who uses the service specifically told us, “It’s a very clean and safe environment.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

There were appropriate staffing levels to make sure people received safe quality care and, when commissioned, 1 to 1 care.

Staff had regular supervision and appraisals, including senior meetings, domestic meetings, and night staff meetings. These regular and tailored meetings allowed the provider to communicate regularly and effectively with their staff team and aid in their development.

A relative of a person who uses the service told us, “There always seems to be loads of staff around when we visit, we always meet a regular face. Compared with [relative’s] previous home the staff are consistent, they really know[relative]and they seem really experienced in dealing with dementia…. When I leave [relative], I feel really confident that [relative’s] being well cared for.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had appropriate waste control measures in place.

In depth cleaning schedules were in place, these covered daily cleans, deep cleans, mattress and cushion checks, equipment, heating and ventilation. A domestic team was in place overseen by a head housekeeper.

We observed good hygiene practices during mealtimes; appropriate use of Personal Protective Equipment (PPE) was used throughout the home.

Relatives of people who use the service gave us comments such as “I’m really happy with how they are looking after [relative]…. [relative’s] clean when I see [them] and [their] room is clean.” Another said, “[Relative’s] always clean and there are no smells in [their] room when I visit.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider followed good practice, as needed medicines (PRN) protocols were in place and captured a good level of detail. These protocols allow staff to safely administer medication when needed such as paracetamol for pain relief.

Temperature checks were conducted twice daily to ensure safe storage conditions for medicines. We conducted random stock checks to Controlled Drugs and found these to be correct and tally up with the providers records.

There was an assigned “Meds Admin” staff member for each shift. This was a senior member of staff who was responsible for managing medicines throughout the shift.

Multiple relatives of people who use the service told us that they were happy with medicines support in the service and they were regularly kept up to date, for example with changes in medicines.