Hatton Grove

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We identified breaches of regulations relating to safe care and treatment. Some risks to people’s safety and wellbeing had not been properly assessed, monitored or mitigated. These included risks within the environment and unlocked cleaning products. Some areas of the building had not been sufficiently cleaned and procedures for managing infection prevention and control were not always followed. Whilst people had received their medicines as prescribed, some of the systems for managing medicines were not being followed and there was a risk to people’s safety and wellbeing because of this. We discussed the concerns were identified with the manager. They took action to put some of these right immediately after our visit. People using the service and their relatives felt they were safe. There were appropriate systems for safeguarding people from the risk of abuse, and for responding to things that had gone wrong. Staff were familiar with these. They and people’s relatives gave us examples of learning and how improvements had been made to the service following incidents and accidents. There were enough suitably trained and qualified staff. They were deployed in a suitable way and there were clear lines of responsibility. The provider supported people with safe transitions between services and worked with external professionals to make sure people felt safe and supported.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were suitable systems for learning when things went wrong. People’s relatives told us they had been informed of accidents, incidents and other concerns. They had been well informed and they told us the staff had learnt from these and made improvements. One relative explained, ‘’They did a good investigation’’ and another relative commented, ‘’They now have better equipment in place.’’ Following any accidents or incidents, the staff recorded these and they were investigated. The manager met with staff to discuss these and learn about how improvements could be made. The manager met with other local care home managers to discuss things that had gone wrong so they could share good practice and learn from each other. The manager had a system for tracking incidents and identifying themes. They told us they were developing this at the time of our assessment.

The provider supported people to access a range of services and transfer between these. Staff had supported people during hospital visits and admissions. They had developed a health passport which gave other healthcare professionals essential information about people’s needs and communication. The provider had supported people with transitions when they first moved to the home, encouraging them to visit and spend time at the service. Staff had visited and worked with people in their previous homes to get to know them and for them to feel familiar and safe with the staff.

Relatives told us people were safe at the service. Their comments included, ‘’They handle money well and in a safe way’’, ‘’My relative feels safe and everybody knows [them]’’ and ‘’They give me peace of mind because [person] is absolutely safe.’’ There were suitable systems for safeguarding people from abuse and mistreatment. Staff received training about these and also had regular opportunities to discuss signs of abuse and the procedures. There were posters and information on display to remind staff and visitors what to do if they had any concerns about abuse. The staff had worked closely with the safeguarding authority to investigate potential abuse and to help put protection plans in place to prevent abuse in the future. People were not restricted in their movement around the home or how they spent their time. For people who did not have the mental capacity to consent to some restrictions, including locked front doors, medicines and equipment such as bed rails, the provider had made applications for Deprivation of Liberty Safeguards. These were monitored and the provider consulted with the relevant authorities to ensure any restrictions were in people’s best interests.

Risks were not always safely managed. There were hazards within the home that had not been properly assessed or mitigated. These included unlocked cupboards containing hazardous cleaning products and electrical wires which were not properly secured or kept tidy. People could access these areas and were placed at risk because there were not proper control measures in place. We found that a specialist air mattress for 1 person had been turned off. This mattress was designed to help prevent skin damage and the person was placed at increased risk when this was not functioning properly. The staff had assessed risks associated with people’s health conditions, activities and lifestyle choices. These assessments gave guidance for staff about how to mitigate risks. However, they had not always been updated with changes in people’s needs and information was not always clear. Failure to assess, monitor and mitigate risks placed people at increased risk of harm.

The environment was not always safely or well maintained. Some cupboards and furniture were damaged, for example cupboard doors hanging off hinges and broken radiator covers. Areas of the building had been decorated nicely, although other areas showed signs of wear and tear and damage. There were risks within the environment which included exposed hot water pipes and damaged flooring. The manager told us they were aware that repairs were needed and were discussing the budgets for these repairs with the provider. People had personalised their bedroom and there were features around the home which made the environment feel homely and reflected individual personalities.

There were enough staff working at the service, they were suitably trained and supported. Relatives of people told us that there were enough staff to support activities and to make sure people’s needs were met. They told us that there was good consistency in the staff team and people were familiar with the staff who supported them. The staff we spoke with told us they had the training, information and support they needed. Many of the staff had worked at the service for a long time and told us how they had known people for many years. There was a robust training programme, and staff were supported to learn a range of essential skills to help them provide safe and effective care. The manager explained how they organised for external professionals to provide additional guidance and training when needed, for example when people developed a new need or healthcare conditions. The manager carried out tests of staff knowledge and competencies. Staff were deployed in an effective way which meant that people’s needs were being met and they were safe.

The systems for preventing and controlling infection were not always being followed. We found areas of the building were not properly cleaned and there were some infection risks. For example, we identified bins, including those for clinical waste, had not been properly covered, ovens and kitchen equipment needed cleaning, some fridges needed defrosting, and some food had not been properly labelled or had passed the use-by date. A hand wash basin in the foyer contained stagnant water, mops and buckets were left after use without being emptied or cleaned and some toilets and bathrooms did not include soap, paper towels or hand sanitiser. Failure to follow safe systems for infection prevention and control placed people at increased risk of harm. The manager told us they had already identified improvements were needed in this area. They had discussed this with the company employed to clean the service. They took immediate action to rectify the areas of improvement we identified during our visit.

The systems for managing and handling medicines were not always safely followed. For example, the fridge used to store medicines was not a pharmaceutical grade and therefore we could not be assured medicines would be safely stored in this. Medicines which needed to be administered at specific time were not always given at the best time for the person. This could impact on their effectiveness. Records relating to PRN (as required) medicines and medicated creams had not always been completed correctly and in line with the provider’s procedures. This meant there was an increased risk of errors. Failure to safely manage medicines placed people at increased risk of harm. People’s relatives told us they were happy with the support people received with medicines. We observed staff administering medicines. They did this appropriately and gave people information about their medicines. The staff were knowledgeable and had undertaken training as well as competency assessments to make sure they knew how to administer medicines in a safe way.