Harmony House

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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

This assessment did not assess all quality statements within this key question and therefore, an overall rating has not been produced. We assessed 5 quality statements; learning culture, safeguarding, involving people to manage risk, infection prevention and control, and safe environment. The homes culture to learn and improve standards of care required improvements. Accidents and incidents were discussed with staff but records did not always demonstrate learning was implemented to mitigate risks further. The provider did not demonstrate an effective system for overseeing accidents and incidents to identify trends to reduce the risk of reoccurrence through shared learning. Risks to people’s health had been identified but records did not always contain enough detail to ensure staff consistently met people's needs. For example, for people identified at risk of choking, specialist advice was not always followed or understood by staff. Records did not always record what people had eaten and whether it was in line with their assessed needs in a timely way. Checks were completed to ensure environmental safety, however these had failed to protect people from the potential risk of harm. We found no evidence people had been harmed however, the provider continually failed to robustly assess all necessary risks relating to the health safety and welfare of people. This placed people at risk of harm. This was a breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People and relatives told us people were safeguarded from the risk of abuse. Staff understood their safeguarding responsibilities People and relatives told us the home was clean. Staff followed safe infection control processes and wore appropriate personal protective equipment when required.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall, when concerns were raised, the majority of people and relatives report these were acted upon. However, learning had not always been taken to support the prompt maintenance of equipment. One relative told us how a person had been unable to get out of bed due to an issue with their equipment. This had not been dealt with promptly or used as an opportunity to put things right, learn and improve. For this person, this resulted in restrictions on their freedom and they were at risk of emotional distress. People and relatives told us that risk's related to the emotional impact of people not being encouraged to get out of bed were also overlooked. One person told us, "I’d like to go out more, have lunch in the dining room but they never take me. The only time I see staff is when they give me my medication and change my pads, otherwise I just lie here all day. I've asked staff to get me up but they say no. They are not bothered about me." A relative commented, "One nurse gets them out of bed the others don’t bother. One day I asked why they were still in bed and she said they hadn’t got time."

Staff told us that learning was taken from accidents and incidents that occurred in the home. One staff explained there had been some manual handling reflective practice undertaken to further reduce the risk of skin tears. Another staff member explained how further learning had taken place around the management of falls. However, there had been a previous choking incident at the home and we found lessons had not always been learned to mitigate this risk further. Staff did not always fully understand best practice guidance in relation to eating and drinking.

Records did not always ensure learning had been embedded. For example, further information was required in care records to ensure staff had the information they required to fully manage known risks. Records did not always specify people's special diets in relation to best practice guidance. Some care records were not completed fully and there was a lack of consistency in the recording of when meals and drinks were offered/consumed to support the management of risk. Accidents and incident records were completed but these were not always analysed effectively to identify patterns and trends to aid learning.

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.

People and relatives told us people were safeguarded from the risk of abuse. Comments included, "I have absolutely no concerns about their safety here. I see everything that goes on", "I’ve no concerns at all, the girls are all lovely" and, "I’m happy here the girls will do anything for you. I feel quite safe, it’s knowing there’s always someone there."

Staff understood their safeguarding responsibilities and knew what action to take should they have any concerns about people's safety. Staff were able to tell us how they would identify abuse and how this would be escalated both internally and externally if needed. Staff were confident the provider would take the appropriate action to any safeguarding concerns raised.

People appeared comfortable in the presence of staff and we saw no evidence of malpractice.

The registered manager had a system in place to ensure all safeguarding incidents were managed in line with the providers expectations. Records showed safeguarding incidents had been referred to the local authority and statutory notifications had been submitted to us, CQC, where necessary.

Some people and relatives did not always feel that there is a balanced and proportionate approach to risk that supports people and respects the choices they make about their care. Some people and relatives raised concerns regarding people being left in bed for prolonged periods of time which increased their risks associated with their emotional well-being. Comments included, "I’d like to get up, it’s a bit boring here. Staff say they can’t get me in to the hoist they are worried about hurting me", and, "One nurse gets them out of bed the others don’t bother. One day I asked why they were still in bed and she said they hadn’t got time."

The registered manager had failed to effectively communicate best practice guidance around eating and drinking to staff who supported people who were at risk of choking. The registered manager confirmed they had booked further training for staff following our visit. Feedback from staff showed inconsistency in knowledge around how people needed their food to be prepared to mitigate the risk of choking. This demonstrated staff had a lack of understanding around risks related to eating and drinking.

In addition to the environmental risks identified during our visit, we also found communal thickener was being used. Thickener is a powder which is added to liquid and used for people who have difficulty swallowing thin liquids. Drinking thickened liquids can help prevent choking. This thickener did not have an open date and therefore it was not clear whether it was within the expiry date.

There was an inconsistent approach to planning people’s care. People's care plans did not always provide staff with the level of guidance they needed to manage risk. For example, in relation to choking, best practice tools were not used in people’s care plans. This meant that staff did not always clearly know what texture or amount of food a person could safely manage, based on best practice standards. There was no date of change for a person's catheter in their care plan. This could pose a risk it would not be changed within 12 weeks in line with best practice guidance. For one person risk scoring tools such as MUST, Waterlow, Barthel had not pulled through into the care plan for staff to read. Care plans to manage people's behaviour were not always person centred or specific to manage risks. There had been 3 choking incidents, yet staff who gave meals and drinks failed to record intake accurately. It was not always clear if care plans had been updated to minimise the risk of choking. However, some other elements of peoples care plans showed other risks had been carefully considered. This included elements of people’s PEG feeding plans. A PEG is a soft tube placed through the skin into the stomach which allows food to enter directly.

People did not raise any significant concerns about the environment. However, one a relative told us about an on-going issue with a person's equipment and told us, "There’s a wheelchair in their bathroom it’s broken and been there since February. I’ve raised it a number of times, they say there’s a part missing and it hasn’t come yet. It means they stay in bed all day which [person] doesn’t like."

Staff told us they felt the environment was safe. They explained checks were completed to ensure environmental safety. Staff told us equipment was suitably maintained and items were promptly repaired when required. One staff member said, “I feel we have enough equipment. We also have spare equipment, such as wheelchairs and hoists are always serviced on time.” Another staff member told us they felt any shortfalls in equipment were quickly addressed and said, “When it comes to the residents [senior staff] try to do the right things.”

Some fire doors were ineffective because they did not close fully or closed to quickly. Hazardous chemicals had been left unattended in an unlocked room. Some window restrictors checks did not have tamper proof screws. Some bedrooms were undergoing a refurbishment and were unoccupied, but hazardous materials and tools had been left in these rooms which were accessible to people. We saw 1 person did not have the equipment they needed to live their lives as they wished. The activities store cupboard instructed staff to keep locked. This was unlocked and contained 3 alcohol bottles and 14 out of date bottles of carbonated drinks which posed a potential risk if ingested.

The provider and registered manager's systems and processes had failed to identify concerns within the environment. Although checks and audits were completed to ensure environmental safety, these had failed to protect people from the potential risk of harm because staff had not always followed or recorded these checks.

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

People told us staff followed good infection control processes and the home was kept clean and tidy. Comments included, "‘They keep his room very clean, never seen dirty clothes or spillages" and, "[Person's] room is quite clean with no spillages. Staff put the clothes away tidily."

Staff told us how they reduced the risk of infection within their working practices. Staff said they were supported to provide good infection prevention through the provider's training, guidance and discussions at staff meetings. The registered manager and senior staff told us they regularly checked areas of the home were clean via daily walk arounds and any issues acted upon.

The home was clean and tidy with no odorous smells. During the on-site assessment we observed staff followed safe infection control processes such as wearing the correct person protective equipment (PPE). There was an area for donning and doffing and plentiful stocks of PPE. Staff took immediate action where spillages occurred so the likelihood of infection were reduced. Waste items were appropriately disposed of by contractors.

Systems and processes were in place to ensure infection control processes were managed safely. This included the completion of infection control audits and organising the rota so house keeping staff worked all days of the week. Records showed meetings with housekeeping staff were held. The provider’s infection prevention policy was up to date. The registered manager and senior staff regularly checked areas of the home were clean. The provider’s infection prevention policy was up to date and promoted good infection control practices.

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