Hepworth 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 requires improvement. At this assessment the rating has remained 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 The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding. Incidents and accidents were not always identified, reviewed and reported appropriately. Risks to people’s health and well being were not always assessed. Safeguarding concerns were not always identified and shared appropriately.

This service scored 41 (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 did not have a proactive and positive culture of safety based on openness and

honesty. They did not listen to concerns about safety and did not always investigate or report

safety events. Lessons were not learnt to continually identify and embed good practice. For

example, Incidents were not consistently identified, recorded or acted on, preventing the service

from recognising them and learning from them effectively.

The service did not always maintain safe systems of care to manage risks people could

experience or be exposed to. We found shortfalls in the provider's systems always being

established or effective in areas such as safeguarding concerns being identified, risks to people

and staff being well managed and care plans always being reflective of people’s needs.

However, we found the service had good communication systems with people's relatives and

other services they used. A relative told us, “What they do well is communication with relatives;

[Registered manager] is always responsive by emailing.” We saw evidence of partnership

working with other professionals, for example, local GP’s and the district nursing team.

People were not always protected from abuse and improper treatment. For example, where

people had experienced harm or made allegations of abuse this had not been reported to the

local authority safeguarding team. Failing to recognise potential safeguarding concerns and

escalating these appropriately placed people at increased risk of harm. Despite our findings,

people told us they felt safe. One person said, “What I can say this is very safe place.” And “It’s

safe and you get used to routine.” A relative told us, “From what we seen [Relative] is safe.”

The provider did not work well with people to understand and manage risks. We found care

plans did not always have risk assessments or information to support staff to keep people safe.

Where these care plans were in place, they lacked sufficient detail to guide staff in how to

support people safely, for example, were people required support with personal care, or with

episodes of emotional distress. This placed people at risk of harm.

At our last inspection we identified a number of concerns in relation to the environment. At this

inspection we saw work had been carried out to address these concerns, as well as some re-

decoration. At this inspection we found some areas remained a health and safety risk. For

example, we found an emergency fire escape was impeded with items stored in front of it, some

furnishings were damaged or broken and where people were at risk of falls, we identified

wardrobes had not been secured to walls. This increased the risk of them topping over, placing

people at risk of harm.

The provider did not always make sure there were enough qualified, skilled and experienced

staff. For example, staff and leaders lacked a clear understanding of legislation and guidance in

relation to restrictive practices. People were at risk of having their human rights violated. Despite

our findings, we also observed call bells were responded to promptly. Records confirmed staff

were recruited safely and received effective support, supervision and development. People and

relatives told us, overall they felt there were enough staff, one person said, “I think there are

enough of them, they come around often.”

The provider did not always assess or manage the risk of infection. We noted some areas of the service had a malodour. We also observed personal protective equipment (PPE) loose behind furniture. We did observe staff wearing PPE appropriately and people told us they felt the service was clean. One person said, “Room is cleaned by staff, it’s very clean and toilet is spotless.”

The provider did not always make sure that medicines and treatments were safe and met

people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified several topical medicines in people’s bedrooms without the correct labelling. This

placed people at risk of receiving medicines that were not prescribed to them or were out of

date. When medicines stocks did not tally, the provider did not have a robust system in place to

investigate and identify the reasons why, this meant the provider could not assure themselves

people were receiving their medicines correctly.