Heartlands

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 requires improvement.

At this assessment the rating has remained as 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 regulation in relation to safe care and treatment. The related to the safety of the care environment and the way people’s medicines were managed.

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 because lessons were not always shared to continually identify and embed good practice.

Staff told us they reported accidents and incidents when things had gone wrong. However, feedback from staff was mixed on learning from incidents and safety events. Some staff said they were not given information about lessons learnt or why things had happened. Others said lessons learned were shared during daily ‘flash meetings’; however, they could not provide examples of any learning shared. This inconsistency suggested that learning from incidents was not embedded in practice and may not have been effectively communicated across the service. Without clear and consistent sharing of lessons learned, opportunities to improve safety and prevent future incidents may be missed.

Care plans and risk assessments were reviewed following accidents and incidents to ensure they remained relevant, and risks had been addressed. People had been referred to other healthcare professionals for advice and support.

The provider had systems to review accidents and incidents to identify any patterns and trends; however. they were unable to evidence any learning that had been identified as result and how this had been measured to reduce risks or shared with staff.

This lack of documented learning outcomes made it difficult to demonstrate how improvements were being made across the service. The leadership team acknowledged this gap and agreed that lessons learned should be more clearly considered and recorded in future. They recognised the importance of capturing learning outcomes to support service-wide improvements. We were assured that they began working to strengthen this process immediately during the inspection.

The registered manager understood their responsibility under duty of candour to be open and transparent with people and their relatives. Where accidents and incidents had occurred, people and relatives were informed.

Relatives confirmed they had no safety concerns and were informed of any falls or accidents involving their family member.

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.

The provider had appropriate processes for new referrals into the service, obtaining a copy of the person’s initial assessment, and then carrying out their own assessment of need, before deciding whether they would be able to meet and provide the care and support required. All new referrals were signed off by the registered manager ensuring that the correct process had been followed and that there is a smooth transition into the service. There was an electronic care recording system in place, which care staff had access to read and understand the care requirements. One staff member told us, “The wellbeing team always do a life story/biography form. This supports with understanding the resident’s care plan.” Another staff member told us, “Pre-assessments are completed by the customer relations manager. She will upload onto Nourish [electronic recording system] and create the person. Sometimes the deputy or registered manager give us a debrief and the paperwork. We usually get [the information] a couple of days in advance, [it is] communicated quite well.” This helped ensure people’s care was provided in a planned, responsive and organised way.

People, and their relatives were listened to by the provider and were involved when initial care plans were being created. This helped ensure people were supported to receive a continuity of care when moving into the service.

People were supported to attend external healthcare appointments; staff discussed the arrangements for these with people’s relatives to ensure they had appropriate support in place. The provider had processes for staff to follow to ensure people’s care records were updated with any healthcare professionals’ advice. One external healthcare professional told us, “I find that the staff follow my advice.”

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.

Staff had received training in how to safeguard people and told us they would not hesitate to report any concerns. People told us they felt safe and knew how to raise concerns about any abuse or neglect. The provider shared safeguarding concerns quickly and appropriately with the local authority safeguarding team and notifications to us, CQC. A member of staff told us, ''I know how to report any form of abuse, and I would take immediate action. I would know who to report to and I would continue to escalate further to the local authority if I needed to.'' Staff could recognise signs when people experienced emotional distress and knew how to support them. For example, a member of staff told us they would know what to say and how to support a person's distress when they became anxious.

Everyone we spoke with felt the service was a safe place to live in. One relative told us, "My [relative] fell out of bed a couple of weeks ago and immediately they ordered crash mat, sensor mat and put sensor on the wall. We feel that [my relative] is safe living here."

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS applications and authorisations were in place for people. Care records contained information to inform staff if a person had a DoLS in place.

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.

The provider’s procedures for assessing, monitoring and mitigating risks within the care environment, which increased the risk of harm to people who used the service, were not effective. We identified concerns in relation to aspects of fire safety; controlled access to high-risk areas; infection prevention and control standards; waste disposal and the effectiveness of maintenance procedures at the service. We also found risks associated with the management of people’s medicines were not always safely managed.

People were involved in the ongoing reviews of their own risks and care plans. They, and their relatives where appropriate, were involved in creating their initial care plan when they moved into the service. This meant people and their relatives were regularly involved in managing the person’s individual risks and ensuring care was provided in line with their preferences.

Care staff were familiar with people’s individual risk assessments and care plans. People’s risk and care plan information was held on the provider’s electronic care record system. Staff had access to information to refer to, via handheld electronic devices, which meant staff could see people’s care plan and risk assessment information and any updates.

Some people living at the service had complex dementia care needs and could demonstrate heightened levels of anxiety or agitation. People’s support plans contained sufficient detail about people’s individual triggers or diversion techniques for staff to use.

Individual risks to people were mitigated. For example, one person’s care records indicated they were at risk of self-harm and control measures were in place to manage this risk.

Care plans in place provided staff with information and guidance to support effective management of associated risks. This included identified risks, in relation to falls, catheter care, skin care and the management of diabetes.

Staff were assigned to specific areas of the home each shift to make sure there was always a staff member in communal areas to keep people safe and mitigate risks.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People were not cared for in a safe environment which was well-maintained, and which supported staff to deliver safe and effective care. For example, the provider’s own maintenance audit had identified concerns with automatic fire doors which were slow at closing. Fire doors are designed to prevent the spread of fire and smoke. If they do not close properly, fire and smoke can travel more quickly through the building, endangering lives and property. This meant people were at increased risk of harm in the event of a fire emergency. We found key-coded doors to restricted areas that had been left open. For example, the door to the sluice room was left open and, on the latch. Sluice rooms contain hazardous substances, posing a risk to people, especially those with cognitive impairments. Additionally, we found combination codes written on door frames to restricted areas, for example the equipment room and cleaning cupboards which compromised controlled access. Visible codes defeat the purpose of controlled access, making it easy for unauthorized access to restricted areas. We raised these issues with the provider who took immediate action to rectify the faults identified.

During the site inspection we observed that people were at increased risk of trips and falls from trailing wires in communal areas. For example, the lounge had a range of fans with extension leads that could potentially lead to trips and falls causing injury and harm to people at the service.

There were processes in place for reporting any maintenance issues identified by staff, people and their relatives. However, we found where concerns had been reported to the provider, remedial action was not always taken in timely manner. For example, handles on 2 doors had been missing for some time as replacements were on order and the provider was experiencing issues locating the correct mechanisms. The provider told us due to the delays in sourcing the correct handles, a supply of handles would now be held in stock for any further replacements. Where maintenance work and repairs were overdue, this had not been followed up. For example, a curtain pole had fallen in a person’s room and had not been repaired. When this was bought to the provider’s attention it was scheduled to be repaired.

The environment was adapted to meet the needs of people living there. People had access to outdoor spaces, providing an opportunity to enjoy fresh air and relax in the garden.

All people living at the service had personal evacuation plans in place which were regularly reviewed a grab bag for the fire service.

The provider had an emergency evacuation plan and staff had been trained in how to respond. The plan included the equipment required in the event of a fire to facilitate an emergency evacuation. Fire equipment had been regularly tested. The evacuation simulation procedure had been scheduled to be practiced and policy amended to quarterly evacuation simulations going forward.

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 had a policy to ensure checks were carried out to ensure the suitability of staff during the recruitment process. This included references and an enhanced Disclosure and Barring Service (DBS) check. Staff told us they had an induction when they started working at the service which included training and working alongside more experienced staff to learn people’s individual needs. The provider was proactive in ensuring staff had the training and support they needed for their role. The provider had implemented Oliver McGowan training on learning disability and autism into their training schedule.

During our inspection we saw there were enough staff to meet people’s needs and keep them safe. Some staff raised concerns about staffing levels during peak care delivery times, for example morning and evening routines. One staff member commented, “We[staff] all get on and we all work together. Staff have been in place for over a year. [There are] a few new people [staff], but we support and help new ones.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We saw staff supporting people at mealtimes and found there to be appropriate support with regards to level of engagement with people whilst supporting them. Staff demonstrated they understood their roles. We observed most people appeared relaxed and at ease when being supported by staff.

Staff were required to regularly refresh their training and were positive about the training and support they received. A staff member told us, “We have training all the time. [It is] mostly online and face to face training for manual handling and some annual training.”

We received some mixed reviews from people and relatives on the staffing of the service. Some felt staff were available when they needed them whilst others felt more staff were needed. One relative told us, “There’s sometimes enough staff. At night time there is two staff and a nurse on the second nursing floor. Sometimes they could do with more staff.” Another relative said, “From what I see, there is always someone [staff] in the lounge. [There are] plenty of staff] inf] about.” Another relative said Staff looked tired. Nonetheless, response to calls for support were immediate if the buzzer went off or generally within minutes. One relative told us they liked the continuity of staff at the home and that no bank staff were used. We observed there was sufficient number of staff over the 2 days of inspection to attend to people’s care and support needs.

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

The provider failed to ensure people were protected from an increased risk of harm from health infections resulting from poor hygiene in some parts of the service. For example, black mould was observed in a staff communal shower toilet area. We raised this with the provider who acted immediately and placed those rooms out of use until work to address the concerns had been completed.

The provider failed to ensure clinical waste was disposed of safely. The external bin store area was not secure and could be accessed by the public. The clinical waste bin was observed to be open with clinical waste bags left potentially accessible. This increased the risk of tampering, unauthorised access, or accidental exposure to hazardous waste with the potential increased risk of infections as a result.

The kitchenette on the first floor of the service was in a poor condition and water damaged which had encouraged mould and bacteria growth. This impeded the ability of the provider’s domestic staff to keep those areas clean. However, this had been identified by the provider’s own audit and new replacement kitchenette was on order and due to be replaced.

We observed the environment was clean and generally smelt fresh. There were housekeeping staff on duty and regular cleaning schedules in place. Regular infection prevention and control audits took place.

Staff had been trained in infection prevention and control. Staff understood when and why they should utilise personal protective equipment (PPE) and we saw this was readily available throughout the building.

People’s relatives raised no concerns about the overall cleanliness. One person’s relative said, “The environment is clean, tidy and safe. The staff are seen wearing PPE.” Another relative said, “The [person’s] bedroom is kept clean and the laundry done. The cleaners keep it clean. The bed is stripped and made ready for the evening.”

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

The provider had policies and procedures designed to ensure people’s medicines were safely managed and staff were trained in medicine administration. However, we found concerns relating to people in receipt of covert medicines. We found that 1 person had been given their medicines covertly, which is when the person is not aware they are receiving medicine, why they need it or how the medicine could impact their health. The provider failed to implement records to ensure the safe administration of covert medicines in line with National Institute for Health and Care Excellence (NICE) guidelines. There was no evidence of signed guidance and instructions from the GP and pharmacist in relation to this covert administration. In response to our assessment, the provider took action immediately to gain written signed consent from health professionals to rectify this and ensure lessons were learnt.

Emergency seizure medicine for epilepsy was stored on the second floor behind 3 locked barriers, while the person lived on the first floor. There was no emergency plan to ensure quick access, and staff had not practiced how fast they could retrieve and administer it. This delay could pose serious health risks. We found there was only 1 syringe of this rescue medicine available in stock, despite the care plan stating that 2 should be ready for a single seizure episode. This shortage could lead to poor seizure control and increase the risk of medical complications. In response to our assessment, the provider took action to rectify this and ensure lessons were learnt.

We found errors in the recording and auditing of the provider’s controlled drugs register. These inaccuracies meant that the provider could not be confident that controlled medicines were being safely and consistently managed. Reliable documentation is essential for ensuring accountability, tracking usage, and preventing misuse or loss of high-risk medications. Without accurate records and regular audits, there is a risk that discrepancies may go unnoticed, potentially compromising the safety of individuals who rely on these medicines.

We were not confident people received their medicines safely and the provider was in breach of regulation related to the provision of safe care and treatment. We shared our findings with the registered manager and provider’s leadership team who started to act during the inspection process to address the concerns raised. We were assured that the registered manager and leadership team were receptive to our findings and committed to making the necessary improvements to ensure safe medicine practices going forward.

People and their relatives raised no concerns about how their medicines were managed or administered. One relative told us,“My [relative] gets paracetamol and pain relief for his arthritis; the nurse records them.”