Himley Manor 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 requires improvement. At this assessment the rating has changed to 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.

The provider reviewed incidents and complaints to ensure issues were identified, well-managed and followed up appropriately. Learning from incidents was shared across the home to support continuous improvement in practice, supported by the deputy manager’s introduction of daily safety huddles.

Meetings involved senior carers and other staff, and focused on matters affecting people’s day‑to‑day care, safety and wellbeing. They were also used to highlight learning needs linked to the delivery of safe support. Additional check‑ins took place later in the day, including scheduled discussions in the afternoon and evening to address any emerging concerns.

Daily huddles covered a wide range of safety and operational matters, with clear actions identified and allocated. Learning from previous incidents was shared during these meetings, and leaders tracked actions and progress, so lessons were learned, and the same incidents were less likely to happen again.

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 service took a collaborative and joined‑up approach to safety. People and those close to them were involved in planning care and transitions. In‑house assessments were completed when people moved into or returned to the home, involving the person, relatives and professionals involved in discharge planning. This helped ensure information was accurate, up-to-date and shared with relevant GP practices, social workers and other healthcare professionals.

People experienced a smooth process when referrals to other services were required. Information was shared appropriately to ensure people received care and support in-line with their individual needs. This included sharing care plans and health information when people accessed healthcare services or external support. Good working relationships with partner organisations supported timely referrals and continuity of care.

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.

People were protected from abuse, neglect and discrimination. People told us they felt “safe” living at the home.

Safeguarding incidents were managed appropriately. Where improvements were needed to provider processes or staff practice, actions were taken promptly and learning was shared with staff. Incidents were reported to CQC and the local authority when required. Staff understood their safeguarding responsibilities and felt confident to recognise and report concerns appropriately.

The provider ensured people were supported in line with the Mental Capacity Act 2005 (MCA). People’s capacity to make decisions about their care was assessed and where individuals were unable to express their wishes, relatives or representatives were consulted to support best‑interest decision making. When people were subject to restrictions to keep them safe, authorisation was sought in line with the Deprivation of Liberty Safeguards (DoLS).

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 deputy manager and staff managed risks to people’s health and safety well. People received safe care which reflected their individual needs and identified risks. Care plans and risk assessments included clear, detailed information about people’s needs and risks, which supported staff to provide care safely and consistently. Referrals were made to relevant healthcare professionals when required, including for risks associated with choking, falls and skin integrity.

Staff showed a good understanding of how to reduce risks by involving people in discussions about their care. Positive risk‑taking was encouraged, where appropriate, to support people’s independence and quality of life. People’s care records included guidance on how specific risks were managed in a way which balanced safety with individual choice.

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

The environment was safe and well-maintained to meet people’s needs and supported individual choices and preferences. Equipment was available to promote people’s mobility and independence, including wheelchairs, walking aids and appropriate bathing and showering equipment.

The provider took effective steps to maintain the safety of the premises. A dedicated handyman was employed to support ongoing maintenance and respond promptly to any issues. The deputy manager completed regular environmental audits to identify and address potential risks in a timely way.

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.

People and their relatives told us staffing levels were sufficient. One relative said, “I’ve never noticed any issues with staffing when I visited [person].” Staff also reported there were enough of them on duty and said they had time to spend with people.

We observed sufficient staff throughout the assessment and staff were knowledgeable about people’s individual needs. Staff had completed the training required for their roles.

Staff were recruited safely. Recruitment records confirmed references were obtained from previous employers, right‑to‑work checks were completed, and Disclosure and Barring Service (DBS) checks were carried out before staff started working there. These checks helped ensure staff were suitable to work with people using the service.

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.

Clear infection prevention and control policies were in place and easily available to staff. Staff told us they understood their responsibilities in relation to infection control and felt confident to follow procedures.

During the assessment, we observed the environment was clean and staff had access to suitable personal protective equipment (PPE), which supported safe working practices. We observed staff following infection prevention and control procedures and responsibilities were clearly understood.

People and their relatives spoke positively about cleanliness within the home. They told us the environment was clean and staff maintained high standards of hygiene. Staff confirmed they had sufficient PPE to carry out their duties safely.

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.

Systems were in place to support safe medicines management, and staff involved people in planning their treatment, including when changes occurred.

People received their medicines as prescribed and on time, including antibiotics, which were reviewed to ensure courses were completed appropriately. Allergies were clearly recorded, and protocols were in place for “when required” medicines.

Medicines were stored safely. The clinic room was clean and tidy, with hand‑washing facilities available to support good hygiene.

There was clear evidence medicines were checked and kept up to date, with current instructions and GP updates recorded when medicines changed. The provider had systems in place to maintain adequate medicines stock levels and reduce the risk of shortages.

Staff had completed medicines training and used reliable sources, including the British National Formulary (BNF), to support safe practice. Incidents and near misses were recorded and reviewed, and medicines errors were reported appropriately. The home had recently introduced a new role for medicine technicians, which helped support medicines management processes and support senior care assistants. These systems supported learning and continuous improvement in medicines management.