Honeybourne 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

We identified 5 breaches of legal regulations. People were not consistently protected from the risk of abuse and/or improper treatment. Staff did not always identify allegations of abuse or make referrals in line with the providers policy and procedures. The provider failed to ensure the premises were properly maintained. We were not assured that the provider was preventing people living at the service from catching and spreading infections. We could not be assured there were sufficient staff on duty to meet people’s assessed needs safely. The culture of the service was not person centred, people were not involved in a meaningful way in the development of their care and there was limited information to demonstrate how staff were engaging with people in understanding their rights, supporting them to have increased opportunities or enabling them to make informed decisions. However, people told us they felt safe living at Honeybourne House, and relatives felt confident with the care and support provided. Other risks to people’s health and wellbeing were being managed well. Where people required specialised equipment to keep them safe, we saw this was in place and staff followed people’s individual risk assessments. People's medicines were stored and mostly managed safely. People were protected by safe recruitment practices. People were mostly supported by staff who had the skills and experience to meet their needs safely. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who were able to share their views with us, told us they felt safe. Relatives told us they were able to raise concerns if something was not right and felt these would be listened to and acted upon. However, we found there was little information to show how staff were actively engaging with people or seeking their feedback. There was limited information to demonstrate how staff were engaging with people in understanding their rights, supporting them to have increased opportunities or enabling them to make informed decisions. People were not involved in a meaningful way in the development of their care and information was not provided in a way which met people's individual communication needs. The culture of the service was not always person centred, did not drive improvement or seen as an opportunity to improve people’s lives and embed good practice. For example, we found staff only raised concerns when it affected them personally, and where staff had concerns, they failed to escalate them in a timely fashion. We observed people in the Bungalow spent prolonged periods without staff interaction despite this being addressed in staff meetings. Two people living in the main House wore handling belts as part of their clothing, staff knew this was institutional practice but were not actively addressing the situation. One person mobilised on a different level, we observed staff step over and around this person without acknowledging their presence. The culture of the service did not always reflect best practice guidance for supporting people with a learning disability and/or autistic people. Staff did not fully understand Right support, right care, right culture guidance published by CQC, or how the underpinning principles could be used to support and enable people to live an ordinary life, and value their contributions. This was a breach of regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The manager told us they used information from accidents, incidents, safeguarding and complaints to learn lessons. These were then shared with the staff team via team meetings and formed part of their ongoing action plan. However, the manager said that they recognised that one of the barriers to improving people’s safety and experience was the culture within the service. They described the work taking place with the provider to improve staff culture, but recognised this was a long-term process. However, they felt positive changes were taking place. For example, staff were now coming forward when they had concerns. The manager explained that all concerns were taken seriously, and we saw evidence of where issues had been raised, these had been shared with other health and social care professionals for guidance and support or as part of the services’ legal responsibilities. Staff told us they knew how to report concerns about people’s safety. They mostly felt able to raise concerns and told us the manager would listen and act.

The provider had systems and processes in place to seek people’s views, analyse incidents, investigate concerns, and learn lessons. However, we found these were not always effective. Accidents and incidents were recorded and reviewed by the manager to identify any learning which may help to prevent a reoccurrence. This information was also shared with the provider through regular monthly meetings and audits. However, we found where safety concerns had been identified the provider, manager and staff had been slow to act [see safe environment and safeguarding sections of this report]. The provider had systems and processes in place to seek people’s views through surveys. However, we found people were not given the opportunity to have their voices heard as information was not presented in a format which was inclusive to all. The manager had started to hold meetings with people to seek their views and listen to any concerns they might have. However, we found these meetings needed time to fully develop and embed. Staff were encouraged to speak up, complete surveys and provide anonymous feedback. There was a suggestion box within the service for staff, service users, family members and visitors to put forward ideas on how to improve the service.

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 who were able to share their views with us told us they felt safe and were happy living at Honeybourne House. Comments included, “Yeah I feel safe here”. One person pointed to the activities coordinator and said, “I really like [Person’s name].”, “Yes…I like the staff” and “I do feel safe, I love the staff.” Relatives we spoke with did not raise any concerns about people safety. Comments included, “Yes lovely they all do a good job, and the manageress is good”, “Yes I do” and “Most certainly, absolutely no qualms [Person’s name] is very safe.”

The manager described how the service protected people from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. All of which was under pinned by the services policies and procedures in relation to complaints, safeguarding, whistleblowing, mental capacity, and deprivation of liberty safeguards. Staff had received training in safeguarding adults and were able to tell us the correct action to take if they suspected people were at risk of abuse and/or avoidable harm. One member of staff said, “I know how to safeguard people, if I ever felt I could not go to the management I would go to the safeguarding team myself.” Another said, “If I witnessed anything I would report it – I have never witnessed any of this, so I have not had reason to do so.”

During the inspection, we observed many positive interactions between people and staff. For example, we saw some lovely interactions which were person centred, and it was clear that staff knew people well and cared about the people they were supporting. We saw staff interacting with people offering choice, asking people how they were and engaging people in everyday conversations. However, we also observed some poor interactions. For example, one person mobilised on a different level. We saw staff walked past and stepped over this person on multiple occasions across all 3 days of our site visit without acknowledging the person’s presence or speaking to them.

There were systems in place to protect people from abuse, including policies and procedures and training for all staff. However, we found the manager and staff had not always recognised when information of concern needed to be shared with the local authority’s safeguarding team for further investigation and follow up in line with the providers safeguarding policy. For example, staff failed to recognise and report possible institutional abuse/neglect, which had impacted on one person’s quality of life. Where some staff had known concerns or had reason to believe people were at risk of avoidable harm, they failed to raise/escalate their concerns within the organisation or to Plymouth City Council’s safeguarding team in line with the providers safeguarding policy until they had been personally impacted. Poor record keeping meant the manager was not aware of an alleged incident as although there were clear systems and processes for the recording and reviewing of incidents, staff had not completed the form correctly. Therefore the incident had not been flagged for review or follow up. Where restrictions had been placed on one person’s liberty to keep them safe, the manager told us this person had capacity and they did not believe that an application should have been made. We found no assessment of the person’s capacity had been completed by the service prior to the application being made to the local authority. The failure to effectively establish and operate systems to investigate and report allegations of abuse and provide care and support in line with the Deprivation of Liberty Safeguards code of practice, placed people at an increased risk of harm. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People we spoke with told us they felt safe and liked the staff supporting them. One person said, “I do feel safe, I love the staff.” Most people living at the service were not aware of their care plan and/or associated risk assessments. Relatives told us they had not been involved in the development or had access to people’s care plans or risk assessments and confirmed that people living at the service would not be able to understand the complexities of their support.

Staff knew people well and had a good understanding of their needs. For example, staff were aware of people's individual risks, potential triggers and signs that might show the person was becoming unwell or anxious. Staff described how they supported people to manage their emotional distress or anxieties.

It was clear from our observations that staff had developed good relationships with the people they were supporting. Staff we spoke with had a good understanding of people’s needs and were skilled at anticipating people’s needs and identifying triggers which might lead to people experiencing emotional distress. Where people required specialised equipment to keep them safe, we saw this was mostly in place and staff followed people’s individual risk assessments.

The manager described how the service assessed people’s needs before offering a placement. Assessments were used to develop person centred care plans and risk assessments. These were reviewed on a regular basis with the involvement of people, relatives, and staff. Care plans and risk assessments reviewed by the inspection team contained clear information regarding risks and provided guidance for staff on how to support people to minimise those risks. For example, detailed care plans and risk assessments were completed in areas such as choking, mobility, moving and handling and managing people’s emotional distress. The provider monitored compliance through a series of audits completed by the manager and members of their internal quality team.

People’s bedrooms were personalised with ornaments, pictures, and other memorabilia to make them feel more at home and reflect their personalities. For example, one person who had a passion for ‘Marvel’ had their bedroom decorated in their favourite superhero theme. However, we found some communal areas and bathroom facilities needed some attention as identified within the observation section of this report.

The service did have in place a maintenance plan. The manager told us they were chasing the provider but accepted that many of the actions had been outstanding for some months with no expected date for completion. The manager told us that one person’s electric bed had been broken for about six weeks. They did have a replacement upstairs, but they did not have anyone to bring it down. A senior manager told us they were aware that some aspects of Honeybourne House needed to be upgraded and assured us there was a plan in place to address these concerns. In addition, they planned to recruit another maintenance person as they acknowledged it was too much work for one person along with their other responsibilities.

We toured the service with the manager and found some areas of the service needed significant attention. For example, the area to the back and the side of the Bungalow which was accessible to people, staff, relatives, and visitors represented a significant trip hazard. We also noted part of the decking was broken. We asked the manager to take immediate action to reduce the risk of slips trips or falls. When we returned for the second day of the assessment, we found action had been taken. The bathroom in the House was in a state of disrepair. Carpets and furniture were stained and looked grubby, and some corridor walls and bedrooms needed repair and redecoration. We also found that the window restrictors in two upstairs bedrooms had been removed.

We cannot be assured the service is doing all that is reasonably practicable to mitigate risks to the people using the service in relation to the environment. During the assessment we found several concerns regarding the general state of disrepair to the premises. Whilst environmental checks and audits were in place. These did not drive improvement within a timely manner. The provider had failed to ensure the premises were suitably maintained for the purposes for which they are being used. This was a breach of regulation 15 (Premises and Equipment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following our site visit the provider confirmed a detailed list of scheduled works along with expected timescales for completion. We were not assured that the provider was doing everything possible to prevent people, visitors, and staff from catching and spreading infections. For example, one person living at the service mobilised on their hands and knees. The manager and staff told us they had not considered any potential risks in relation to the risk of or spread of infection to the person or others. Systems and processes to manage soiled laundry within the service were not being adhered to by staff. On the third day of the assessment, we found laundry bags containing soiled linen and clothes had been hung from the banister in the House. Poor infection control procedures and the failure to follow clear workflow systems within the laundry placed people at an increased risk of harm. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not able to tell us if there were enough staff to meet their care and support needs. However, most relatives did not raise any concerns about staffing levels. Comments included, “Every time I’ve been, there’s been loads of staff around.”, “Most of the time yes.”, “Yes definitely. I don’t know about nights and weekends.” However, one relative said, “There is one nurse and four carers for seven people who require two to one support for all their personal care needs. They are expected to take people out, but can’t be due to staffing.”

Staff consistently told us there were not enough staff on shift to meet people’s needs. Comments included “No, I do not feel there are enough staff,” “There are times when things are going on and 2 staff have gone out and that leaves 2 on the floor. Sometimes I do not think that is enough.” And “No, we don’t have not enough staff, because we have 1 person that needs one to one all the time and that leaves 3 people on the floor for 7 people and most of those people need two to one for all personal care, and that leaves 1 person.” Staff did not always receive regular supervision. The deputy manager said, “We had quite some severe delays with supervision, so it has been difficult to complete them.” A staff member said, “I think I have had 3 or 4 supervisions since I have been here, I think it is every 3 months.” Another said, “I have not had a supervision this year, the last time I had one was when [Person’s name] was here, so sometime in second half of last year.”

We could not be assured that staff were employed in sufficient numbers to meet people's assessed needs safely. On the first day of the assessment, we observed people in the Bungalow spent long periods of time without any interactions from staff. People were sat around the outside of the room. In the middle of which was some sensory equipment and there was a television playing the radio on the wall. We noted one person was being supported by a staff member. However, at no point within the 30 mins we spent observing did we see the staff member interact with this person. There appeared to be more staff within the main house. For example, there always appeared to be a member of staff within the communal lounge / dining room interacting with people. In addition, we noted staff in the main house were also supported by the services management team.

The manager told us there were enough staff to meet people’s needs and explained they had recently updated the services dependency tool. The manager provided us with a list of people’s additional one to one funded support hours but told us they did not know what these were for. We asked if the additional commissioned hours had been included as part of the staffing dependency tool. The manager confirmed they had not. We obtained a list of additional hours from the local authority and found these did not match the information provided by the manager. There was no system in place to identify if people were receiving additional support as per their funding arrangements. This meant we could not be assured people’s care and support needs were being adequately met. Systems in place to ensure staff received appropriate support, training and supervision were not effective and could not be relied upon. For example, clinical supervision records did not promote personal and professional development. The services clinical lead told us they could not remember the last time they had received clinical supervision. Records showed staff were receiving regular supervision, however we found staff supervision did not improve staff performance or promote a positive culture within the service. For example, senior staff told us about concerns relating to one person’s conduct. We looked at this person’s supervision records and found none of these concerns had been openly discussed, mentioned, or addressed. The failure to provide enough skilled staff who are adequately supported to meet people's care and treatment needs, is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were protected by safe recruitment practices. Records confirmed a range of checks were carried out before staff started working at the service.

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 received their medicines in a safe and caring way, and records were kept when medicines were given. People’s individual preferences for how they liked to take their medicines were taken into account. Some updating of protocols for people’s ‘when required’ medicines were needed, although staff were able to tell us when doses might need to be given.

Staff told us they felt medicines systems generally worked well and they had supplies of medicines when they needed to be given. Staff were trained in medicines administration and had competency assessments. However staff reported that they assessed each other, and it was not clear how much oversight the manager had of these assessments. There had been some errors, however staff described appropriate systems for dealing with these, reporting them and putting any learning in place.

There were processes in place to ensure people received their medicines safely. However, there were some areas for improvement to records of temperature ranges and application of patches. We recommend that the provider seeks advice from a reputable source to ensure systems are put in place to record patch application sites and checks are undertaken to make sure these are being applied safely. And that temperature ranges are monitored for medicines needing cold storage to ensure they are always stored at suitable temperatures.