Harrier Lodge

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 inadequate. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a proactive and positive culture of safety in the service, based on openness and honesty. Staff listened to concerns about safety, investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood their responsibilities to report concerns, incidents and safety events, and felt able to do so. Incidents and accidents were appropriately recorded and reviewed, and there was evidence that learning was identified and shared across the service. For example, a regular “lessons learned” bulletin was circulated to staff, which outlined incidents that had occurred within the home, alongside actions taken and key learning points to support improvements in practice. These were also discussed at handover meetings.

The registered manager and senior management team reviewed incidents on an ongoing basis and shared learning with staff through team communication and reflective discussions. Staff demonstrated reflective practice following incidents, including considering the possible reasons why events had occurred. Where issues were identified, appropriate actions were taken.

Senior management reviewed incidents on a monthly basis to identify patterns and trends, supporting learning and improvement. For example, they had identified repeated incidents of people rolling out of bed and had explored changes to mattress types to see if it would reduce risk. However, we found they had not considered whether the bed size was appropriate for individuals’ body shape and size. We discussed this with the provider, who acted promptly to consider this as a possible contributing factor and made adjustments to bed size where required.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

While systems were in place to support transitions, including pre-admission assessments, review of information and appropriate referrals, these were not consistently effective in ensuring people’s safety or continuity of care. Staff understood when to contact specialist services, and we saw examples of referrals being made and external input provided.

However, healthcare professionals raised concerns about delays in seeking support from services. For example, staff did not always follow agreed referral processes despite repeated reminders, which could lead to delays in people accessing the support they required and a lack of timely action when concerns arose.

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.

A person told us, “Yes, I feel safe.” A relative commented, “Yes, relative is safe here.” Staff had completed safeguarding training and demonstrated a good understanding of their responsibilities. They were able to recognise the signs of abuse and understood the need to report concerns promptly. Staff told us they would escalate concerns to the registered manager without delay and were aware of their duty to whistle blow if required. The registered manager understood their responsibility to safeguard people from abuse and promote people’s rights.

The provider shared concerns with relevant agencies quickly and appropriately, which helped ensure people were protected and any risks were addressed in a timely way.

The provider acted in accordance with the Mental Capacity Act 2005 (MCA), which provides a legal framework for making decisions on behalf of people who may lack capacity.

Where people lacked the mental capacity to make specific decisions, these were made in their best interests and in the least restrictive way. Records showed that best interest decisions were made involving people and their representatives to support their care delivery.

The provider ensured that any deprivation of liberty was carried out lawfully and only when it was in a person’s best interests, with the appropriate legal authorisation in place under the MCA. Staff had received training in the MCA and understood their roles and responsibilities in promoting people’s rights and protecting their freedom.

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.

Care plans and risk assessments were up to date and guided staff in providing safe care and managing identified risks, including risks associated with falls, skin integrity, choking, and moving and handling. Moving and handling risk assessments and care plans were in place to ensure people were supported safely when being assisted or repositioned.

The provider had implemented appropriate measures to reduce the risk of falls and injuries. These included the use of low beds, sensor mats and fall mats where required, which helped to minimise potential harm.

Where people required monitoring, appropriate charts were in place, including those for weight, fluid intake and repositioning. These were completed accurately and used to inform care delivery. Where specialist equipment such as pressure-relieving mattresses was in use, settings were documented and regularly checked to ensure they remained suitable for the person’s needs. Changes in people’s needs were communicated to staff through documented handovers.

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

Systems were in place to identify, monitor and manage environmental risks effectively.

A fire risk assessment had been completed, which supported the provider in identifying and mitigating fire-related risks within the service.

Health and safety checks were carried out regularly, including checks of equipment used to deliver care. Records demonstrated that equipment was maintained appropriately to ensure it remained safe for use.

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.

People and their relatives generally felt there were enough staff available. Nine out of 10 relatives we spoke to told us there were enough staff to support people safely.

Feedback included: “When I have been there, there has been enough staff, but I know they do struggle at times as they use a lot of agency staff,” “Certainly on the floor where I go, there are always four to five staff,” “There is always a member of staff in sight. They check on my relative regularly,” and “I have never seen a problem with staffing; there are always staff around helping people.” Other comments included, “Yes, there is always plenty of staff – my relative is on the dementia wing,” “Yes, I do think so; I don’t know about night time but certainly during the day when I visit,” and “I have never walked in and found there are not enough staff; there always seem to be plenty, and staff are visible.” However, one relative said there were not always enough staff available, particularly when people required support from two staff members.

Staff told us they felt there were enough of them on duty to meet people’s needs safely. A staff member said, “I think we are enough certainly. We are not rushed at all.” Another staff member explained, “With the number of residents in the home currently, we are enough. As more people come in, management will increase the number of staff to match.” Our observations during the inspection supported this, as staff were visible and available to support people in a timely way. The provider planned staffing levels based on people’s needs and occupancy.

Records showed that new staff received a structured induction, which included role-specific training and opportunities to shadow experienced staff. Staff spoke positively about the support they received, including regular supervision, team meetings and annual appraisals to reflect on their practice and develop their skills. Training records confirmed staff had completed mandatory training as well as additional learning to meet people’s specific needs.

Recruitment processes were safe and robust. The provider carried out appropriate pre-employment checks, including references and Disclosure and Barring Service (DBS) checks, to help ensure only suitable staff were employed.

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 home was clean, well maintained and free from unpleasant odours during our visit. There were dedicated domestic staff responsible for cleaning, who followed appropriate infection prevention and control procedures and used personal protective equipment (PPE) as required.

Care staff also demonstrated good practice in relation to infection control. They used PPE appropriately and followed established procedures to reduce the risk of cross-contamination and protect people from infection. Staff understood their responsibilities in maintaining a safe and hygienic environment.

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

Medicines were managed in line with national guidance. They were stored securely and in appropriate, temperature-controlled conditions. Records showed that medicine administration records (MAR) were completed accurately, supporting safe administration practices. Protocols were in place for medicines prescribed ‘as required’ (PRN), such as for pain relief, and records confirmed that the effectiveness of these medicines was monitored and clearly documented.

Medicines were administered by nurses or staff who had received appropriate training and whose competency had been assessed by the clinical lead. Training and competency records were comprehensive, up to date, and demonstrated ongoing oversight of staff practice.

Systems were in place to monitor medicine errors. Incidents were appropriately recorded, investigated, and lessons learned were shared during clinical meetings to reduce the risk of recurrence. Staff completed reflective accounts following errors, which were used as a learning tool to improve practice and promote a culture of continuous improvement.