Honeybrook 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

At our last inspection we rated this key question requires improvement. At this assessment we did not assess all quality statements within this key question. The overall rating for this key question remains requires improvement based on the findings of the last inspection. This meant some aspects of the service were not always safe and there was limited assurance about people’s safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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.

During this inspection we found that some processes required improvement to ensure people were not unlawfully deprived of their liberties and that all actions in response to safeguarding incidents were completed. Although not all people were free to leave, there were no Deprivation of Liberty Safeguards (DoLS) regarding this restricition. This meant people were unlawfully restrained. When safeguarding investigations resulted in action plans, these were not always completed within the timeframe specified by the provider.

Staff had been provided with training on how to recognise and report abuse and they knew how to apply it. A member of staff told us, “If I witnessed abuse I would report it immediately to my registered manager. If immediate action was not taken, I would make a report on (electronic system) as I have access to it. I will also make a complaint on the Care Quality Commission website.”

It was clear that staff knew people well and communicated with them in an appropriate and respectful manner. Staff were vigilant in monitoring people's moods and behaviours and provided care in accordance with people’s needs. Staff provided reassurance when people needed it, they knew people's routines well and ensured they followed these. There was clear guidance about how people communicated and how staff should respond.

During this assessment we found that some processes required improvement to ensure people were not unlawfully deprived of their liberties and that all actions in response to safeguarding incidents were completed. Although not all people were free to leave, there were no Deprivation of Liberty Safeguards (DoLS) regarding this restriction. There were no best interest meeting decisions and Deprivation of Liberty Safeguards (DoLS) in place to protect people’s rights. This meant people were unlawfully restrained. When safeguarding investigations resulted in action plans, these were not always completed within the timeframe specified by the provider.

People and most of their relatives told us that people’s needs were assessed, and they felt involved in the assessment process. One person’s relative told us, “I am involved in his care, they always ask me.”

Staff told us there were appropriate systems in place to monitor people’s safety and address risks to people’s health and well-being. These included risks relating to people expressing feelings or emotional reactions in an inappropriate way. A member of staff told us, “We complete referrals to positive behaviour support (PBS) lead or health care professionals if needed. Safeguarding concerns have been raised previously.”

During our assessment we saw that staff informed people about risks and reminded them to take appropriate action, such as to choose right clothing, take their medicines or be careful around wet floor. Not everybody who used the service was able to express their views verbally. Staff were aware of body language and signs people used to express their needs and feelings and what these were likely to mean. Staff provided reassurance when people needed it, they knew people's routines well and ensured they followed these.

At our last inspection we found that systems were not in place or robust enough to demonstrate risks to people were effectively managed. 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. At this assessment we found that the provider was no longer in breach of regulation 12. Individual risk assessments had been undertaken to enable people to retain their independence and make their own choices, whilst minimising risk. Systems were in place to identify and reduce risks to people using the service. Risks associated with people’s health and welfare, including the risks of falls, nutrition, dehydration, incontinence, developing pressure wounds, and hazards resulting from using bed rails had been assessed. Staff were provided with relevant guidance to follow to minimise the risk of harm. Each person had a personal emergency evacuation plan (PEEP). A PEEP sets out the specific physical and communication requirements that each person has to ensure that people can be safely moved away from danger in the event of an emergency.

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

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.

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

People could take their medicines in private when appropriate and safe. Staff made sure people received information about medicines in a way they could understand. People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely.

Staff told us they received training in administration of medicines and had their competency to administer medicines assessed to ensure they continued to use safe best practice. Staff understood their roles in the safe management of medicines. Where staff were responsible for medicines administration errors, the registered manager took appropriate action and organised additional supervision to ensure that staff followed appropriate processes.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles. Medicine administration records (MARs) confirmed people had received their medicines as prescribed. There were appropriate arrangements in place for recording and administering prescribed medicines. There were also effective processes for ordering the stock and checking the stock at the home to ensure the medicines provided to people were correct.