Healey Lodge Residential Home

“Incidents and accidents were not always well recorded and records relating to pressure care and hospital passports were not always robust. Risk assessments relating to people’s specific health conditions were not detailed enough to guide staff and risks to people were not managed well. The environment was not always safe and not all servicing records were readily available at the time of the assessment. Staff were not recruited safely and interview notes were either not completed or accurate. We found gaps in staff training and views on staffing levels were mixed. We found concerns relating to infection prevention and control and not all staff were aware of who had a DoLS (Deprivation of Liberty Safeguards) in place. People’s consent was sought as appropriate. Medicines were not being managed safely. Staff knew the process should someone fall and staff knew what to do should they have a safeguarding concern.”

“People’s goals and ambitions for the future were not recorded and not all relatives felt they would be informed when people’s needs changed. Distressed behaviours were not managed or recorded well and although people’s weights were being monitored, it was not clear what action was taken for those who were experiencing weight loss. Risk assessments relating to oral health were not detailed enough. People had their needs assessed prior to their admission to the service and a wide variety of food was on offer, taking into consideration people’s specific dietary needs.”

“Activities were not always person-centred and we saw no evidence of activities taking place during the weekend. Some concerns were raised in relation to staff communication and language barriers. People’s independence was encouraged and staff felt valued working at this service.”

“Care plans held conflicting information and required updating. Not all documents were available in accessible formats and we found concerns in relation to confidential information not being secured. Complaints were not always formally investigated and we saw no evidence of people or relative meetings taking place. Referrals were being made as necessary and staff spoke of how they would use different forms of communication to interact with people. Partners felt the service was accessible and people’s advanced wishes had been discussed as appropriate.”

“Work was needed to improve the culture of this service to ensure everyone was treated equally and fairly. The registered manager and nominated individual held conflicting views about this service and staff supervisions were not taking place frequently. A range of audits and quality checks were in place but did not pick up on the concerns identified during our assessment process. The provider was not always working in line with their own policies and there was limited evidence of lessons learnt processes. Staff were aware of the term freedom to speak up and told us the registered manager was approachable and knowledgeable. Partners felt the service worked well with them to ensure joined-up effective care.”

“We found 5 breaches of the legal regulation. The provider was previously in breach of the legal regulation in relation to safe care and…”