High Lea House

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 Good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could not be assured lessons were learned following accidents and incidents, as we found gaps in records where incidents had not been investigated. For example one person had fallen 10 times but only 1 incident had been investigated to identify ways to prevent it from happening again. This potentially placed people at risk of avoidable harm.

We also found that actions recorded as being taken in reviews of incidents and accidents had not always been completed. For example, review notes stated that a person had been referred to GP after a fall, but management were unable to provide evidence this had happened.

The provider did not always respond to concerns raised by external agencies in a timely manner. The Environmental Health Agency had instructed the home to make improvements, but these had not been addressed by the time they revisited, and some were still outstanding at the time of our visit.

The provider did not always work well with people and health care partners to establish and maintain safe systems of care.

We found that the provider did not always respond to risks to people identified by health professionals. For example, we found that 1 person had been identified, by a health professional, as requiring a modified diet to reduce the risk of choking. No information was available to staff advise them of this risk or to help them support the person with their diet. During lunchtime we observed staff serving food to the person which was unsafe and increased the risk of choking. We shared this with the manager and owner, who took immediate action to contact the relevant professionals and obtain guidance and develop a plan of care.

Although policies and procedure were in place to protect people from the risk of abuse, these required strengthening to ensure that they were effective. The home had policies for safeguarding and whistleblowing but these lacked detail and were out of date. At the time of our visit the policies were not held at the home, so were not available for staff to refer to.

People told us they felt safe living at the home. One person told us “I feel very safe and very well cared for.”

Staff had completed training in how to recognise abuse and were able to tell us how they would respond if they felt abuse was taking place.

We received mixed feedback from staff about their confidence about raising concerns to management, due to a recent dismissal of a staff member.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw no evidence in care plans that people had been consulted about how they wished their safety to be managed.

Where risk assessments had been completed for people, they were not always robust or contained information to help guide staff to manage the risk identified. For example manual handling assessments did not include guidance for staff to ensure they handled people safely.

Where risk assessments or plans for people had been written these were not always updated to reflect their current needs. For example, we found evacuation plans had not been reviewed and people who were now immobile were identified in their plan as being independently mobile. This placed people at risk of not being evacuated safely in an emergency.

Where the provider had identified measures to reduce risks to people, these had not always been actioned. For example, one person had been identified as requiring an alarm fitted to external doors to manage the risk of absconding in April 2024 but at the time of our visit the door had not been fitted with an alarm and was unlocked throughout our visit. The manager and owner advised us that an alarm would be fitted to the door as part of planned works to the call bell system and would increase observation of the person in the interim.

People were not protected from the risk of burns and scalds. We found checks were not being made to ensure hot water from outlets was being maintained at a safe temperature. Pipework in several locations was uncovered and allowed contact with the hot surface. We shared the concerns with management, who took immediate action to cover the pipework and introduce regular hot water checks.

People were not protected from the risk of falls from heights. Window restrictors were not installed with tamper proof fixings which meant they could be removed with simple tools such as a knife. We shared the concerns with the management who took immediate action to change the fixings to tamper proof versions.

People were not protected from the risk of crush injuries. Heavy items of furniture such as wardrobes had not been anchored to the wall. We shared concerns with management who took immediate action to secure the wardrobes.

We found a cupboard containing cleaning products unlocked and unsupervised. This cupboard contained products that if misused could be hazardous to people’s health and should be kept behind a locked door when not in use.

People could not be assured that equipment used to assist them to move was in a safe condition. We found that hoists were overdue a service. We advised management, they arranged for them to be serviced.

People were exposed to an increased risk of carbon monoxide poisoning. A room which contained a boiler did not have a carbon monoxide alarm installed. There were also no regular checks carried to ensure they were working correctly. We advised management, who arranged for an additional alarm to be installed and introduced regular checks.

Appropriate checks were not in place to protect people from the risk of legionnaires disease. Unused outlets had not been flushed as required and checks carried out to ensure the hot water system was reaching a sufficient temperature. There were no records to show shower heads were being descaled regularly.

People could not be assured that there was sufficient staff to meet their needs, and that staff were safely recruited.

Staff we spoke to shared concerns that staffing levels were low and this impacted on their ability to support people safely. The provider told us that they had recently increased staffing in the morning but had no formal method for deciding how many staff were required to meet people’s needs.

Staff were not always recruited safely. We found that full employment histories had not been obtained. This meant the provider could not be assure that staff were fit and proper people to work with vulnerable adults. The provider carried out Disclosure and Barring Service (DBS) check prior to them commencing at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Training records showed staff had not been provided with face-to-face training for manual handling people. This meant their competency in embedding learning into practice had not been assessed and they had not been practically trained to use equipment at the home to assist people to move. This meant people were at an increased risk of harm through poor manual handling techniques.

After we shared these concerns with the management, arrangements were made for a review of employment records and practical manual handling training sessions were booked.

People could not be assured they would be protected from the risk of infections. We found some equipment and surfaces had not been maintained to a standard where effective cleaning and disinfection could take place. For example, the varnish on the arms of chairs in the lounge was worn away, wallpaper in an ensuite toilet which was not waterproof and was peeling from the wall and broken and missing tiles in a shower room. When we shared our findings with management, they took immediate action to rectify the issues.

People could not be assured that meals would be prepared in a hygienic environment. The home had been visited by an Environmental Health Officer in October 2024 which identified several required improvements that had not been corrected after a previous visit. We found that a number of these improvements had still not been implemented. We found records of kitchen checks such as fridge temperature, food probe records and cleaning tasks were incomplete. Food was being stored in the corridor outside the kitchen. Care staff had to prepare food and drink in the kitchen at times when a cook was not working at the home.

After the first day of our visit the food stored in the corridor had been moved to the kitchen and at the end of our visit the provider informed us, they were creating an area where staff could make drinks and snacks for people to avoid them having to enter the kitchen.

People could not be assured their medicines would be safely stored and administered.

We found one person was using a prescribed cream which was highly flammable. The risks to the person and the environment had not been assessed. The cream was not being stored in accordance with the manufacturer's instructions and was found on a windowsill in the persons bedroom, where it could be exposed to direct sunlight creating a fire risk.

We found other medicines were stored securely, and regular checks were made to ensure the temperature of the storage areas was appropriate

Staff were trained to ensure medicines were used safely and effectively and their competency to embed this learning was assessed.