Handford House Care Home

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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 assessed a total of 7 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question is now inadequate. Some people did not feel safe. The service had 2 infectious disease outbreaks which placed people at risk of harm. Whilst the provider was working with healthcare professionals to curtail the outbreak, the environment was not being maintained hygienically. People were not safeguarded from abuse as safeguarding processes were not robust. We also found there were insufficient numbers of staff to meet people’s needs in a timely manner. This resulted in a breach of Regulation 12 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from people and their relatives about the culture at the service. A person told us the service was not a happy one and there were divisions between the staff team, which had not been addressed by the management. A relative told us they had raised concerns about the service provided, but when improvements were made, they were rarely sustained. Another relative said they felt areas for improvement were not identified by the registered manager until they pointed them out. The relative was more confident that improvements would be made going forward due to the local authority and CQC visiting the service. Another relative told us they had raised concerns but did not feel they were acted on and addressed.

We received mixed feedback about the culture at Handford House with some staff highlighting our assessment and visits by external professionals had prompted improvements at the service. A staff member said, “Handford is a well-led home, especially following the inspection. The areas needing attention have been addressed, and necessary steps have been taken.” However, 8 staff told us they felt the service was not well-led and their concerns were not listened to and acted on. A staff member told us, as a team they had been threatened with disciplinary action, rather than addressing shortfalls with the individual staff involved. Therefore, improvements had not been made due to the lack of individual accountability. We identified there was a lack of 1 to 1 supervision at the service for staff members. We could not see evidence of performance discussions taking place with individuals.

Six people required 1 to 1 support from staff, to keep themselves and others safe. We observed staff with these people, as required. We noted there was inconsistencies in how the staff engaged with people. Care records did not detail the support and engagement the 1 to 1 staff were to provide. Several people remained in their bedrooms, many with their doors open. Some people walked with purpose around the service. We did not see people entering other people’s bedrooms, however, we saw staff were busy supporting people with their needs and they were not always visible, for example in corridors to monitor people's whereabouts. Staff may not always available to divert people from entering other people’s private space because they were assisting people with their needs.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

A relative told us how a safeguarding referral to the local authority had been investigated following their family member experiencing falls. The relative had not been informed of the falls by the service and no explanation was provided by the service until they had asked for one. Another relative told us how they had raised a safeguarding alert with the local authority regarding concerns about their family member’s care. This was due to the relative not receiving satisfactory responses from the service in relation to their concerns 5 relatives told us how other people, who used the service, went into their family member’s bedroom uninvited and that they were concerned about their family member’s safety and privacy. Some relatives told us their family members had told them they felt nervous when other people entered their bedrooms. This was confirmed by people using the service.

Staff told us they had received training in safeguarding and understood their roles and responsibilities. A staff member said, “We have various posters to remind us how to report abuse if and when it is needed. We also have specific training sections on this… I very strongly believe that all of the residents are safe and cared for in relation to all departments.” Another staff member told us, “I have received training and have been taught how to report abuse and neglect and I know who I am meant to talk to if I would like to report anything.” Despite this we found significant gaps in training provided to staff in safeguarding and mental capacity, the training matrix provided to us during our assessment showed 7 care staff and 3 nursing staff had not received this training. We did not see any training provided to staff relating to supporting people to with their distressed behaviour. We asked the management team how staff were being provided with training, due to some people displaying these behaviours. They told us this was included in the safeguarding training, which we identified, all staff had not received. Staff had raised concerns with us that there were several people living in the service who displayed behaviours others may find distressing. Staff did not feel they had the training required to appropriately support people displaying these behaviours. Staff also told us that staffing levels impacted on keeping people safe at all times.

Six people required 1 to 1 support from staff, to keep themselves and others safe. We observed staff with these people, as required. We noted there were inconsistencies in how the staff engaged with people. Care records did not detail the support and engagement the 1 to 1 staff were to provide. Several people remained in their bedrooms, many with their doors open. Some people walked with purpose around the service. We did not see people entering other people’s bedrooms, however, we saw staff were busy supporting people with their needs and they were not always visible, for example in corridors to monitor people's whereabouts. This meant that staff may not always be available to divert people from entering other people’s private space because they were assisting other people with their needs.

The provider's safeguarding processes were not robust, they had not ensured that all staff had received training in how to protect people from avoidable harm. All staff had also not received training in supporting people with distressed behaviours and how to keep them and others safe. The guidance provided to staff in people's care records relating to supporting people with distressed behaviours was not detailed enough for staff to recognise when a person may be becoming distressed and what actions they should take to support them. This put people at risk. A log of safeguarding concerns was maintained, this included the concern, outcome and lessons learned to reduce future risks. The service was working towards an action plan to address concerns raised. The local authority had an organisational and individual safeguarding enquiries ongoing at the time of our assessment. They had made the decision to not place any service users into the service until improvements had been made. Commissioners and safeguarding staff were in the process of monitoring improvements being made.

Although some relatives reported that staff had taken action to keep their loved one safe, we also heard concerns about staff not acting to keep people safe from slips, trips and falls. A relative told us how they had found their family member wearing someone else’s slippers which were 2 sizes too big which placed them at risk of falling over. Another relative said their family member had fallen when they were supposed to be receiving 1 to 1 support, they had not been informed of this by the service. A relative told us how their family member had been assessed as needing a walking frame to mobilise, this had not been seen since their family member moved in and when they had asked staff, they were told their family member did not need it.

Prior to our assessment, we had received concerns from external professionals about how the service was managing wounds and skin injuries. A member of the management team told us the wound tracker had been reviewed and updated and staff were made aware to report and record any injury and/or wounds to the skin. It had been recognised by the management team that improvements were required, following feedback from external professionals. In addition, the management team understood improvements were required in how staff provided support to people to reduce the risks of skin damage, including repositioning, this was not yet fully implemented, and we found during our assessment shortfalls in this area. A member of the management team told us a visit from the tissue viability nurse, which had been arranged due to concerns raised by other professionals about wound care, had been positive and no concerns were raised relating to dressings and wound management. The regional clinical lead and the service’s clinical lead had attended a link study day, which the service’s clinical lead usually attended, held by the tissue viability team. The member of the management team told us the support would be ongoing and further training would be provided to nursing staff.

We observed a person sitting at the dining room table sitting in a wheelchair, their head was level with the edge of the table, which was a risk that they could hit their head on the edge of the table. We fed back to the management team about the potential risks to the person. This had not been identified until it was pointed out. Staff were present in the dining rooms when people were using the room for meals, to ensure people were safe and any risks could be removed. However, staff were not always visible in other shared areas. For example, staff were not visible to ensure people who walked with purpose were kept safe. We observed shortfalls in the safety of the environment and in the hygiene of the service, which had not been identified by the service until we pointed it out. This placed people at risk of harm.

Staff did not always act to keep people safe from harm, including the risk of developing pressure sores. Prior to our assessment we received concerns about how the service identified and managed any wounds people developed, placing people at risk of harm. A tissue viability nurse had attended the service and reviewed their wound management processes, whilst they did not raise concerns, they continued to support the service and provide training and guidance to staff in wound care. We found improvements were needed relating to the support people received with moving and repositioning to reduce the risks of pressure damage. During our assessment, records showed people were not always supported to reposition in line with the timescales identified in their care records. Records also showed a person, who was at very high risk of skin pressure ulcers, was being supported to reposition to the same position. This increased the risk of developing a pressure ulcer. People’s care records included risk assessments, in areas such as mobility and skin viability. However, there was limited guidance for staff in how to mitigate risks to keep people safe. For example, a person’s records advised staff to pay attention to the person’s skin and report concerns to the nursing staff. Another person’s records identified the risks associated with their health condition. However, there was no guidance in what staff should be looking for including signs and indicators and when they should report.

We received some mixed feedback from people and their relatives about the safety of the environment. A relative said, “The extractor fan doesn't work and has been raised on numerous occasions.” They also told us that in their family member’s previous bedroom, there had not been running water on occasions which they reported to the service. Another relative told us their family member’s wardrobe door was not securely attached, they had reported this to staff. Another relative said they had raised concerns about their family member’s bedroom which included rotten skirting boards. We received further feedback about the general cleanliness of the environment and items being found on the floor, which could cause a tripping hazard in people’s bedrooms, such as medicine pots. A relative also told us they had noted sticky floors, this could cause confusion to people living with dementia when they are independently mobilising.

We received some mixed feedback from staff about people’s safety. A staff member said, “I feel as though some of the people using the service are well cared for and safe. However some of the residents that have recently come to the home, their behaviours can be quite challenging, and this has cause other residents to be at risk.” Another staff member told us how they felt the environment was not always well-maintained and safe and it took a long time for reported issues to be addressed. Some staff told us they felt the staffing levels in the service impacted on people’s safety. The management team told us how they monitored health and safety checks were being completed to ensure the service was safe.

The environment was not always safe. For example, part of the hand rail in the ground floor corridor was coming away from the wall. A bookcase in the activity room was not attached to the wall, which could cause harm to a person if it fell, this risk was addressed immediately by leaders when we told them about it. We saw further environmental risks and pointed out how the television in the activities room, which was plugged into an extension cable hanging off the floor during our first visit and how this could be a risk of someone pulling the television over or tripping over the cable. This was unplugged by a member of the management team, and they advised this would be addressed. On our second visit we found the television had been plugged back into the extension cable. We saw there were 2 passenger lifts in the service. One was out of order, the registered manager told us it had been out of action since 21 June 2024, and they were awaiting repair. We had not been notified of this; the registered manager has since sent us a formal notification after we had pointed this out. The second lift had a crack to the glass inside, there was a film cover over the break to reduce risks to people, this was awaiting replacement. We had also not been formally notified, until we asked the registered manager to do so, of an incident in the service where the environment was damaged by a car.

We found gaps in the staff training records, relating to fire safety and health and safety. The records did not evidence that staff were receiving up to date guidance on how to keep themselves and people using the service safe. We were told improvements were being made. There was a programme of redecoration ongoing, which was not yet fully implemented. Other systems were in place to ensure that equipment, such as moving and handling equipment including hoists were regularly serviced and checked. The checks also included the call bell system, profiling beds, window restrictors and walking frames. Where the service had identified shortfalls in the ways safety checks were made and recorded, this was being addressed. There was a business continuity plan in place which identified actions to be taken in case of an emergency, such as gas leak.

We received mixed views from people using the service and relatives about the numbers of staff. A person said, “I do not think there is enough staff at night, 2 care and a nurse [on each floor], if they are in with someone who needs 2 staff and the nurse is doing [medicines] you have to wait, there are buzzers going off all the time.” Another person told us they felt things had deteriorated in the service and often had to wait, “Sometimes half an hour,” for their call bell to be answered. A relative said, “The biggest negative for the home is the staffing level, there have been various occasions when my [family member] has pressed [their] button for the staff to assist [them] and has had to wait for 30 minutes or more for someone to assist [family member]. I think this also manifests itself in times when planned activities have been cancelled or delayed.” Another relative said, “Not enough staff, although they say they have the right capacity. If this is so, why are they always too busy when asked to do something?” Other relatives described the impact of the staffing levels on their family members. A relative told us the staff had told their family member they were short staffed, which made their family member worry, they felt guilty and stopped asking for assistance, such as to have a shower. Another relative told us how they and another relative had supported their family member with their personal care needs when they could not find staff to support them. They told us they had asked staff where PPE could be found but was not asked why it was needed and the staff member did not return. They added, “Staff are lovely, but they are short staffed, they work hard.” Another relative told us they supported their family member at meal times as they did not feel the staff had time to support them at their own pace.

The majority of staff told us they felt there were not enough of them to provide person centred care to people. A staff member said, “No. Absolutely not. They have the minimum of care staff on duty, especially considering what the upper management expect of us… purely because the needs of the residents are too much for the low level of staff we are allocated. Especially in the morning.” Another staff member commented, “I don’t think resident’s choices are fully met, simply because staff shortages, pressure on care staff not having time to properly do their job… staff are over worked, stressed in trying to do their best… I can see stress levels in staff, they are exhausted overworked. Many staff are talking about leaving.” Other staff told us of concerns with 1 staff member saying, “It can be a lovely place to work in with amazing residents and some great staff. I have however had to raise certain issues around the standard of care residents are being given and the conduct of some staff members. Each department (laundry, maintenance, activity, nurses, night/day carers) is frequently short staffed and /or badly managed. This sometimes leads to a lack of clean clothes, bed linen, cleaning and personal care supplies. Also, an array of different agency workers in and out.” Whilst staff told us they had received the training they needed to do their jobs and to meet people’s needs, there were significant gaps in the training records reviewed. Staff told us they had attended group supervisions and team meetings, however, not all had received 1 to 1 supervision meetings to give them a forum to receive feedback about their work, discuss any concerns and identify any training needs. A staff member said, “I don't feel supported, supervision is well overdue and not tailored for staff, attending staff meetings is keeping up to date with updates and new policies.”

Improvements were needed in the deployment of staff. For example, during breakfast we saw a staff member in the dining area on the first floor, who was responsible for providing people with drinks and food and preparing trays for the people who remained in their bedrooms. Staff who had been supporting people to get ready for their day had assisted people into the dining room and left, instead of offering them a drink and food. We saw a person shouting out, “Where is my breakfast?” They said they had been happy watching television but had been brought to the dining room only to find their breakfast was not ready and had to wait for it. We saw staff were available in the communal areas when people were present. However, several people remained in their bedrooms, some were alone for periods of time. Staff were busy supporting people with their physical needs, resulting in the interactions people had with staff being ‘task focused.’ There was only 1 activities staff member which reduced the opportunity for people to have social interaction and activities. We were told by the management team they were planning to recruit further activity staff.

Prior to our assessment we had received concerns about the staffing levels in the service. We found staff were visible but very busy and task focused. We asked for the provider’s call bell audits, due to receiving concerns from people and relatives about having to wait for their call bells to be responded to. These were not provided, a member of the management team advised they could not be located. We were not assured people were supported by staff who had the appropriate training and skills. Training records showed significant gaps in staff training. 26 care/nursing staff had not completed dementia awareness training, and 10 care/nursing staff had not completed safeguarding and mental capacity training. We reviewed 3 recently recruited staff member’s personnel files. None of these records included records of staff probationary meetings with their line manager to discuss their progress in their new role nor 1 to 1 supervision meetings. We also reviewed the personnel records of 3 longer standing staff members, these included records of group supervisions, but there were no 1 to 1 supervision meetings for the last 12 months, apart from annual appraisals. Supervisions provide staff with a forum to receive feedback, discuss concerns and identify any training needs they may have with their line manager.

We received several concerns from people and their relatives in relation to infection prevention control processes at the service, both during and prior to our assessment. A relative said, “There has been a recent outbreak of MRSA in the care home and whilst I understand care homes are vulnerable to such infections. I do wonder if hygiene standards are all they might be. I have never seen members of staff wearing aprons, gloves or following hand washing routines. In fact, I can’t remember ever seeing a hand sanitiser station anywhere in the home, not even a bottle of hand sanitiser in any rooms or toilets.” Another relative commented, “[The service is] not always clean, sometimes sticky floors, plastic pill containers on the floor, paper on the floor, general cleanliness [is an issue].” A relative told us they had been made aware of the outbreak, and seen notices on people’s bedroom doors, but were concerned that these doors were being left open. They did tell us they saw staff wearing PPE and washing their hands. Another relative said, “I know they have Strep and MRSA, they let us know and use PPE if we want.” Other relatives told us of cleanliness concerns at the service with a relative saying, “The bathroom could use a proper clean, there is an unclean toothbrush mug and surfaces.” Another person’s relative told us they had raised concerns with the registered manager relating to soiled continence pads being left on the floor. A relative told us they had asked staff to address drink stains on their family member’s bedroom wall, when this had not been done, they attended to it themselves, and found the flooring was unclean underneath the furniture.

We received mixed feedback from staff about how infections were prevented and managed within the service. A staff member told us, “PPE [personal protective equipment] has been a bit of an issue, we have occasionally run out of gloves, hygiene wipes and even clear bags for the pads to go into.” Another member of staff said, “There is food under the beds, in wardrobes, sometimes bedding is stained, toilets are dirty.” Some other staff were more positive with one telling us about the improvements recently made following visits by external professionals, “I feel the cleaning has got better through the past few months with new recruits and more staff as staffing has been a problem over the past year or so... we have PPE stations to make it more convenient and safer to grab PPE when necessary.” The registered manager told us they regularly walked around the service to monitor what was happening and if any areas needed addressing. However, they had not picked up on and addressed the hygiene issues we identified during our assessment.

The service was not clean and hygienic, despite 2 recent infectious disease outbreaks. Some immediate actions were taken when we identified issues, however, we were concerned these issues had not been independently identified and addressed. During our first visit, we found the kitchenette on the ground floor was unclean, there was food and drink stains up the walls, the hand wash and washing up sinks were stained and had limescale around the taps, the urn used for hot water was unclean, as were the sugar and coffee canisters and the plastic containers which held cereal. These items were being used daily to provide people with food and drink and actions had not been taken by staff to ensure the equipment they were using were clean and hygienic. We also observed bathrooms had limescale around the taps and the plugholes and overflows were unclean. A shower room had a shower screen which was unclean, with a dark substance on the edges and corners. Toilets had enclosed toilet roll holders to reduce cross contamination, however, we found in a bathroom 3 toilet rolls on the toilet hand grab rails. Not all of the light pulls in bathrooms were wipeable to reduce cross infection and many were visibly dirty. We also found a toilet brush sitting in dirty water in the holder. We observed staff washing their hands and wearing PPE where required. We observed staff washing their hands and wearing PPE where required.

The processes for monitoring the hygiene in the service were not robust enough for the service to independently identify and address the risks we had identified during our visits. Prior to our assessment we were made aware by the local authority of 2 infection outbreaks at the service. We received concerns from health professionals regarding the infection control processes at the service and the management of the outbreak to keep people safe. They had also identified issues with handwashing and the use of PPE. People’s relatives had been notified of the outbreak by letter, which was sent prior to our assessment. A copy of the letter was displayed above the signing in book to advise visitors of the outbreak and PPE was available if required. As a result of the infection concerns, a service improvement plan had been put in place which identified the improvements needed in relation to infection prevention and control. We saw an infection control audit undertaken in July 2024, this followed guidance provided by external professionals, which had identified the planned improvements. A handwashing audit was also reviewed, which showed staff were observed washing their hands.

We received mixed feedback from relatives relating to if they felt their family member received their medicines when they needed them. Some relatives told us that their family member did not always receive pain relief when required. For example, a relative raised concerns that the signs and indicators of their family member being in pain was not always being identified by the staff and appropriate action in response, despite them telling staff of these signs. Another relative told us, “While I visited recently [at the same time as a visiting professional], they were quite surprised to discover the lack of painkillers prescribed. When asked, the in-house nurse's response suggested my [family member] was not asking for anything, therefore an occasional paracetamol would suffice. [Family member was living with dementia], so needs due diligence from those around [them] to be functional, with regards to medication.” Some relatives were positive about the support their family member received but concerns were raised with us that communication around people’s medicines was poor. A relative said, “They do not let us know if they are running out of medication or if the GP made changes, we asked for [specific medicine], they said the GP stopped it, when we asked why they did not know, so we called the GP, but by then they had run out.”

Staff told us they felt adequately trained to administer people’s medicines. A staff member said, “Medication it's done safely, and training is provided, had competency checked 2 months ago.” A staff member shared that they had been asked to support people with medicines when they had not been trained to do so. They told us, “I have been asked to support people giving medication, but I don't do it as I have not been trained but a lot of people do it. I’m not sure whether they have been trained or not. It depends on which nurse is on.” We spent some time with a member of the management team who was completing a medicine audit on the ground floor. They explained what they checked during their audits, they found medicines were dated and when they were opened but not all had the expiry date after they had been opened. The staff member told us that this could be calculated by 3 months after the opening date. We watched medicines being counted and checked against the running total in the controlled drugs book, which were correct. Following medicines management concerns being raised by external professionals. The management team told us they were making improvements in relation to the recording and administration of creams and emollients. Following medicines management concerns being raised by external professionals. The management team told us they were making improvements in relation to the recording and administration of creams and emollients. We were also told actions would be taken, after we pointed out a discrepancy in how the administration of people’s medicines, in the form of patches, were recorded.

Some people required their medicines to be taken covertly. Covert administration is when medicines are administered in a disguised format without the knowledge or consent of the person receiving them. When a person has mental capacity to make the decision about whether to take a medicine, they have the right to refuse that medicine. They have this right, even if that refusal appears ill-judged to staff or family members who are caring for them. There was relevant paperwork in place to evidence that appropriate actions and guidance was sought relating to people receiving their medicines covertly when they lacked capacity to make decisions. However, there was a lack of documentation to show when medicines had been given covertly or when they had agreed to take them. A member of the management team told us this was because those who required to the given their medicines covertly were always given them in this way. A person’s medicine administration records (MAR) from 25 June 2024 to 22 July 2024 for a medicine, had 2 signatures for some of the administration but there were 9 entries which had the signature of only 1 staff member. We raised this with the management team who told us the controlled drugs book should have 2 signatures as well as the MAR. We checked the controlled drugs book on 26 July 2024 and found that 2 signatures were in this document. Action was taken when we pointed out an incorrect name for a person and date of birth for another person, on their medicine front sheet. There was an entry in a person’s records which stated their medicine patch could not be located when staff had planned to remove it. We fed this back to the management team, who investigated the issue. A medicine audit undertaken in July 2024 showed that shortfalls identified included expiry dates were not always recorded on medicines following their opening and people were not always receiving their prescribed creams, such as twice a day.