Heeley Bank 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

During our assessment of this key question, we found concerns around the safe delivery of care, the management of risk and how the service shares and uses important information with outside agencies. This resulted in a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities). You can find more details of our concerns in the evidence category findings below. The systems in place to learn from accidents and incidents required improvements to ensure they were effective and to safeguard people from avoidable harm. However, people told us that they felt safe at the service, they were happy and that they knew who to speak to if they were concerned.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they felt the service was safe, and that they were able to raise concerns if they needed to.

Staff members told us they knew how to report incidents. The management team told us that initiatives were in place to support learning from accidents and incidents, however they were aware improvements were required to peoples care plans and the quality of incident reporting in the home. The management team at the home advised us that they had had difficulties in ensuring that staff were completing their duties in line with planned care.

The provider had not ensured that the systems in place to make sure managers and staff learned from events such as accidents and incidents, concerns, whistleblowing, and investigations were effective.

People and their relatives told us they were happy with how the service worked with other agencies. A relative told us ‘[My relative] had a very smooth and helpful transition into the service’.

The leadership team told us that they were in the process of updating people plans and information to ensure this was accurate, and that this work was ongoing. They were able to demonstrate how information about a person could be shared across service. Staff and leaders at the service told us they felt they have a good working relationship with professionals who spend time at the service. The leadership team were able to demonstrate how information about a person could be shared across services.

Health and social care professionals who have current involvement with the service told us there were problems with how the service shares and uses important information. Professionals told us that the leadership within the service was not effective at ensuring peoples are needs were met safely and that important information relating to people’s care is not always followed by staff. Professionals gave examples of information which had been requested but not returned to them or had been given with insufficient detail.

Information documented within peoples plans and throughout the service was not always accurate or detailed enough to ensure safe and effective care. Important information relating to people’s dietary needs was not effectively shared within the service, and during the inspection we observed people not receiving care in accordance with their plans. This placed people at risk of harm.

People told us they felt safe, and they knew who to speak to if they had concerns. A person told us ‘I do feel safe here, if I was worried, I would pick the right person to speak to.’

The leadership team told us that staff at the service did not always follow instructions of how to care for people appropriately. This placed people within the service at risk of harm. We were told that improvements were being made to information sharing within the service to try and address these issues. Staff told us they felt they knew who to contact in the event of a safeguarding incident.

During the inspection visit we observed people being supported in ways that was not in line with their planned care. We also observed unsafe use of moving and handling equipment. On two occasions staff were observed to not know the names of the people they were supporting. This placed people at risk of avoidable harm. Concerns were fed-back to the leadership team and actions to address these specific concerns was taken.

The processes in place at the service were not effective in ensuring that care was delivered safely. Information about peoples care needs is not always followed, and some information recorded at the service about people lacks sufficient detail to allow for accurate analysis. The service responded appropriately to accidents and incidents that occurred but was not working in a way that proactively prevented avoidable harm to people.

People and their relatives that we spoke to were happy with the care provided. Relatives told us they had been involved in the care planning process and had been kept up to date with changes as they happened.

Managers at the home were able to provide examples of people and their relatives being involved in care planning. Managers told us there were processes in place to share information internally with staff, but not all staff followed care as planned. The management team advised that they were implementing new processes at the service to improve information sharing and compliance.

During the inspection we observed care and support being delivered which was not in accordance with peoples agreed plans. We also observed inconsistencies in information that was recorded, for example nutritional information in people’s plans was not accurate and up to date in food preparation and serving areas. This placed people at risk of avoidable harm. Concerns were fed-back to the leadership team and actions to address these specific concerns was taken.

Processes were in place to involve people and their relatives in the care planning process. The plans that were in place for people were not always followed by staff at the service. Where restrictive practices were in place, documentation relating to the planning and legal considerations relating to these were not always present. The leadership team amended this during the inspection.

People told us they felt safe living at the service and raised no concerns regarding the environment.

The management team advised that they had processes in place for ensuring environmental safety within the service and were able to provide evidence of this.

The premises and equipment at the service were observed to be maintained safely.

Processes were in place to ensure that health and safety checks of the premises were completed in line with current legislation.

People told us they were happy with the care provided to them by staff at the service, however some people commented that staff numbers were insufficient. A person told us ‘There is and there isn't enough staff. They can't spend a lot of time with me, there are lots of people here.’

The management team at the service were aware of incidents that had taken place involving unsafe care delivery. Although additional processes, training and feedback to staff had been put in place to attempt to mitigate future incidences these had been unsuccess in ensuring a sustained improvement. This placed people at risk of avoidable harm. Recruitment was completed safely within the home, with all relevant checks including DBS and right to work having taken place.

Inspectors observed care delivery that was not in line with peoples care plans. This placed people at risk of avoidable harm. Feedback was given to the management team about concerns observed and actions were taken to mitigate future instances, however on a return visit to the service a further incident of unsafe care delivery was observed.

Processes were in place to monitor staff training and competence however these had not ensured that staff were delivering care at a safe level consistently. Individual supervision sessions were not taking place, but managers advised that these were due to be reintroduced. There was insufficient clinical leadership within the service. The provider was in the process of recruiting additional clinical lead staff and had put in place some cover however this only covered 3 days per week. The provider had not followed their own policy in relation to onsite management skills and qualifications as stated in the providers business continuity plan.

People told us they were happy with the levels of cleanliness and hygiene within the service. People at the service told us ‘It's always clean and tidy’ and ‘I see them [staff] wearing an apron when they are dealing with food’.

The management team advised about the process in place for daily checks of infection prevention and control measures within the home. Staff told us they had received training in infection prevention and control and understood how to use personal protective equipment appropriately.

The service appeared generally clean and tidy during the inspection, and staff were observed to be cleaning areas appropriately. Cleaning products were stored safely. Some furniture within the service had visible stains and required cleaning, this was fed back to the management team to rectify. Issues were noted in relation to personal care items in communal bathrooms that were unlabelled, this included disposable razors, a comb, and a body sponge. Feedback was given regarding this but on a return visit these items had not been removed. This creates a potential infection control risk if these items are shared between people within the service.

Processes were in place to ensure that staff were undertaking cleaning duties and managers had a process in place to check this work was completed. However, these processes had not identified the issues that were observed in relation to the cleanliness of furniture and items in bathrooms.

People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR). Staff interacted kindly with people whilst conducting the medicines administration round. Care plans were detailed and ensured staff knew how to support people’s individual needs. Records showed that medicines reviews were completed at least annually by local GP’s.

Staff were trained to ensure that medicines were used safely and effectively. Staff were trained in medicines administration and had competency assessments completed annually. This ensured staff could safely administer medicines.

There were processes in place to ensure the safe and effective use of medicines. This was supported by an electronic medicines administration record (e-MAR). However individual fire risk assessments for people prescribed paraffin-based skin products were not completed. Thickeners used to thicken fluids for people with swallowing problems were not recorded when they had been used. Temperature records to ensure the safe storage of medicines were not always completed in accordance with national guidance and the providers medicines management policy. Audits around medicines use were completed routinely. However, the areas for improvement that we found during our inspection had not been identified.