Highbury House Mental Health Unit

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• 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

We identified 1 breach of legal regulations in relation to risk management. Potential risks to some people had not always been considered and assessed to mitigate the potential impact to people. Fluid monitoring was not always consistent to reduce the risks to people. Some people's medicines records were not in place or updated to ensure staff had the required guidance to follow. However, staff knew people well and care plans and risk assessments provided staff with guidance on how to support people safely and manage risks. Systems were in place to support people moving into the home. Systems were in place to record and learn from any safeguarding’s, incident and accidents. People's rights under the Mental Capacity Act 2005 were supported and understood by staff. There were enough trained staff available to deliver support to people who had been recruited safely. People told us they felt safe when being supported by staff.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives felt their transition into the service was safe and they felt involved with the process. One relative said, “We received good support throughout the process. An assessment was completed of [person] needs, and we were fully involved with this. The move into the home went smoothly which was good. I as a relative was provided with the information I needed and was supported by the staff.”

Staff and leaders described the process that was undertaken before a person was admitted to the home. A pre- admission assessment would be undertaken which would then be discussed with the staff to ensure they could meet the person’s needs. The skills of the staff were reviewed to ensure staff had the required knowledge to meet the persons needs. A staff member told us, “We receive information about the person, and then they are supported to come and visit so we can meet them, and they get to meet the other people that live here.” The registered manager told us how they also work in partnership with external professionals as part of the transitional process. This included regular meetings, and sharing of information to ensure the home was a suitable placement which could meet the persons assessed needs.

As part of this assessment, we asked for feedback from the local authority and external health professionals involved in a person’s recent transition to the home. The local authority told us they had no concerns to share, and they worked well with the staff and leaders at the home. We received positive feedback from external health professionals. One professional told us, “The manager and team are very responsive, and they work well with us. The recent transition into the home went smooth and well informed. The Manager or a deputy attended all the weekly meetings and contributed ideas and solutions to issues that arose. They were very supportive in the transition and accommodating. What echoed most about the transition was how they managed to engage the person and build rapport quite quickly. It was person-centred, the person was able to choose and be included in the set-up of their room.”

We saw and records confirmed assessments were completed before people moved into the home. This showed the involvement of the person, relatives, and external health professionals. However, we saw no evidence from the information shared if there was any consideration of people’s suitability and compatibility with the people already living in the home in respect of age range, complexity of people's primary needs, and gender. We saw a 72-hour care plan and risk assessments were formulated from the pre- admission assessments, and visits to provide staff with information and guidance on how to support people’s needs.

People told us they felt safe living in the home and when being supported by staff. One person told us, “I feel safe living here and if I had any concerns I would speak with the manager or deputy.” A relative told us, “I have no concerns, I think [person] is safe. The staff are all lovely, respectful, and kind. If I had any concerns I would raise it with a staff member.” People told us their consent was sought before staff supported them. One person said, “The staff always explain and then ask before supporting me, they are really good.”

Staff we spoke with were aware of their responsibilities to report and act on any concerns. A staff member told us, “If I did (see abuse) I would report it straight away to the management team or higher if needed.” Staff told us how any learning from safeguarding incidents were shared with them in meetings. The registered manager told us how safeguarding people is discussed during meetings and in supervision with staff. The registered manager shared learning from a recent safeguarding incident, and actions taken in response to this. People's rights under the Mental Capacity Act 2005 (MCA) were upheld. The staff and management understood the principles of the MCA and the impact this legislation had on their role. A staff member told us, “We have training about MCA and the Mental Health Act, and information is recorded in people’s care plans and risk assessments. Some people have conditions where their liberty is restricted, so we have to ensure we work in accordance with these laws to keep people safe.”

We found some potential risks to people has not always been considered in order to keep people safe. For example, people’s previous historical risks which could impact upon people’s safety. We saw people moved feely both inside and outside in the grounds of the home, which were secure to enable people this freedom of access. We saw people were able to make their own drinks independently within the kitchen area. We observed staff provide emotional support to people who were emotionally distressed providing comfort and reassurance.

Although systems were in place to safeguard people from abuse and avoidable harm, we found some instances where peoples safety had not always been considered. For example, people’s previous historical risks and the location of people’s bedrooms. The management team were clear about their responsibilities to safeguard people and reported any safeguarding concerns to the local authority and CQC. Information was displayed for staff and people to see about the safeguarding procedures and how to report any concerns. People’s rights under the Mental Capacity Act 2005 were fully supported and understood by staff. Records confirmed staff had completed training. Where required appropriate legal authorisations were in place to deprive a person of their liberty. Systems were in place to monitor these and their expiry dates. There was evidence of best interests’ decision-making for people who were subject to restrictions.

People felt staff knew and understood their risks and felt safe when supported by them. Relatives shared these views. A relative told us, “Staff know [person] well and their medical and mental health needs. They act quickly and seek medical attention when needed and keep me fully informed. The staff know how to manage [person] when they are low in mood and provide the emotional support and reassurance they need.”

The registered manager told us how they had regular meetings to discuss people’s needs, and risks. Where applicable support plans, and risk assessments, where updated. The registered manager advised they also had regular Multi-disciplinary meetings with health professionals to discuss people’s needs and when needed to gain further guidance on how to manage risks for people using the service. However we found the compatibility of people was not always discussed as part of these meetings and potential risks considered to ensure these were taken into account. Staff we spoke with were aware of risks to people and their role in monitoring and managing these. Staff confirmed risk assessments were in place and updated regularly as required. Staff told us they felt confident in managing people’s responses to situations and their expressions of concern and emotional distress. A staff member said, “We monitor people’s mood and presentation, and I know how to escalate any concerns or changes to people’s needs and risks.” Staff confirmed they had received training in how to de-escalate situations and as a last resort how to restrain people’s movements safely. Staff confirmed they received de-briefing sessions to discuss incidents and how these were managed. Staff said they felt supported by management following incidents. Staff told us how they supported people in a way to encourage independence whilst monitoring any associated risks.

We observed the location of some people’s bedrooms had not always been considered when they had moved into the home. Action was taken following our visit in response to this with people’s consent. We observed CCTV (which was installed internally and externally for people’s safety) did not cover certain areas of the corridors where some people’s bedrooms were situated. This meant if incidents occurred the CCTV could not always be relied upon to show the factual timescale of events. We observed staff were following risk assessments to keep people safe. For example, ensuring they supported people at mealtimes who may be at risk of choking and checking people’s whereabouts at the required frequency. We saw all staff were wearing alarms for their safety and to ensure they were able to request support from other staff if needed.

Although detailed risk assessments were in place based on people’s individual needs, we found some potential risks had not always been considered. For example, people’s previous historical risks. This meant staff did not always have clear guidance to follow which could place people at risk of harm. Action was taken to address this following our visit. We also found where people were at risk of not drinking enough fluids, the monitoring of their intake was not consistent to escalate low fluid intake. We found for some people this was due to a system error whereby, the monitoring system was turned off. This was addressed during the site visit. A new handover form was introduced following our visit which included any ongoing risks for people including low fluid intake to ensure this was handed over to staff on the next shift. Systems were in place to record and learn from incidents or accidents. These were reviewed by the registered manager to see if any immediate action was needed to mitigate the risk. They were then analysed monthly by the registered manager and provider for patterns and trends and action recorded where needed, of how risks to people were to be mitigated. Learning from incidents was shared with staff and this was confirmed by staff during our discussions. Various methods were used for this including meetings, and supervisions.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us there was enough staff on duty to meet their needs. People had confidence staff had the required training to meet their needs. A Person said, “I think there is enough staff on, I can do what I want so I am never stopped going out because of staffing. The staff are good, respectful and know what they are doing so yes, I think they are trained.” A relative told us, “I think there is enough there is always someone about. The staff have the skills as they know how to support [person] with their needs. Staff know [person] well and the others. Staff are lovely and always speak to me.”

Staff and leaders felt there were enough staff available to meet people’s needs. One staff member said, “There are enough staff on duty to support people and where needed additional staff are on duty. There is always a good skill and gender mix of staff as well to ensure people needs are met. Staff told us they felt supported in their roles. A staff member said, “I have all the training I need for my role and regular supervision; we all work well as a team. The management team are approachable and supportive, it is a great place to work.” The registered manager told us how they monitored the staffing levels by completing observations and feedback discussions with staff. They also considered people’s risks and how many staff were required to keep people safe. The registered manager spoke about the importance of having the right skill mix of trained staff on duty to meet people complex needs.

We saw there was enough staff to support people’s needs. We saw staff were available when people needed them. For example, to support with personal care, activities, or for a chat. The home employed an activities staff member to support with therapeutic activities, and we saw them working with groups of people engaging in various activities. Staff monitored people’s whereabouts, so we saw them both inside and outside the home with people.

Systems were in place to monitor the staffing levels such as a staff risk assessment and dependency tool. However, the dependency tool did not consider people’s mental health and emotional needs and the impact this may have on the staffing requirement. . The risk assessment in place did include this information so there was no impact to people. The provider acknowledged this and advised work was planned to make the tool service specific. Staff had received the required training to ensure they were trained to support people. This included core training and training that was specific to people’s individual needs. For example, staff had completed the required training in communication with people with a learning disability and autistic people. We reviewed the training matrix, and this confirmed staff training was up to date. Recruitment checks were undertaken to ensure staff were suitable to work at the home. Checks had been carried out with the Disclosure and Barring Service (DBS) and references had been obtained. Disclosure and Barring 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. Where gaps in employment were found these were explored and addressed.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were supported with their medicines. Medicines were given safely, in a timely manner, and according to their personal preferences. Administration was recorded on an electronic medicine administration record (eMAR). Where medicines to manage anxiety and agitation were used these were as a last resort and when other non-medicine options had been unsuccessful. People received medicines safely and as prescribed at the right time Considerations were given when medicines needed to be taken before or after food, or when medicines had specific dose intervals. Electronic medicine administration records (eMARs) were updated accurately and in a timely way when medicines were started, changed or stopped. People’s preferences of how they preferred to take their medicines were recorded. People when observed interacted well with staff and were seen to be settled. People told us they felt supported to take their medicines in the service. When required (PRN) medicine use was not seen to be excessive to manage anxiety and agitation in people at the service. De-escalation methods were used to support people before using medicines.

Staff were trained in medicines administration and had competency assessments completed annually. This ensured staff could safely administer medicines. Staff knew people living in the home well and that allowed them to manage medicines safely. Staff told us they enjoyed working at the unit and felt they were part of a team that was caring and making a difference to people living at the service. Staff were knowledgeable about people in the service and knew each person’s preferences with medicines. Staff understood and followed procedures to ensure people’s medicines were reconciled when they moved between services and when changes occurred by the GP or hospital. Staff had signed a paper sheet ‘medication administration: staff list of authorised signatures’ that was dated 2022 in a folder in the clinic. The paperwork stated to be reviewed 6 monthly. The provider on the day of the inspection agreed that a new sheet needed to be put in place and has since been updated.

There were processes in place to ensure the safe and effective use of medicines. The provider had relevant policies, procedures, and training for medicines. The provider did regular medicine audits to ensure medicines were managed safely. However, some documents to support staff lacked detail and were not always person-centred. For example, a person’s care plan who was taking an antipsychotic medication was seen to be lacking information regarding the medicine. The care plan said to refer to the eMAR for information, but this also contained no details about the medicine. For one person prescribed the antipsychotic clozapine, their care plan did not have who to contact for advice and support if needed. Risk assessment for people on sodium valproate were not always present in care plans. However, since the inspection the provider has added the contact details and risk assessments into care plans for the relevant people. When required (PRN) medicine protocols sometimes were missing or lacked sufficient information to support staff to understand how and when to administer a medicine to a person. The provider has now taken action to address the PRN protocols since the inspection. A form titled ‘medication to accompany a person during a temporary absence’ 5 out of 8 forms had no person’s name on the form but it was observed to be completed with a list of medicines. No name on the forms could lead to errors of people getting the wrong form when they left the service for an absence. Paperwork that was being used to record and check the site of patch application was specifically for patches that are changed every 72 hours however the provider was also using this sheet for patches changed every 7 days. This meant the form became difficult to follow when used for 7 day patches concerning the site of the application. Paper records of Epilepsy emergency care plans, were observed to be out of date for 2 people, however electronic versions were in place and had been updated.