Te Hira Care Home Limited

This inspection was undertaken as an aged rating, and we reviewed all 5 key questions under our single assessment framework.

We identified 2 breaches of the regulations in relation to safe care and treatment and good governance.

Governance systems were not fully effective. Systems to monitor the quality and safety of the service needed improvement. We found a number of areas of risk including fire risks related to environment that required attention. These concerns presented a risk to people’s safety, including the risk of injury or harm in the event of a fire. Care plans and risk assessments relating to people’s needs had been completed but they lacked key details to ensure a safe and consistent approach by staff. This meant staff did not always have clear guidance to manage risks safely including risks associated with medicines, infection prevention and control, and the environment.

Staff had a good knowledge of the people they supported and knew their communication preferences which helped them to provide person centred care. Staff were able to access health professionals for advice and support when needed. Staff completed medicines training, but we found there were some areas in relation to medicine management that needed improvement.

Systems were in place to record and monitor accidents, incidents and safeguarding concerns. Staff understood how to recognise potential abuse and knew to report any concerns to management for escalation and investigation. The environment was subject to regular health and safety checks, but records did not demonstrate that risks were effectively identified, monitored or acted upon. This meant it was not possible to determine that risks associated with the environment were always effectively managed and all areas and equipment were safe.

On the day of our inspection visit staff were visible and available to support people’s needs. It was not possible to confirm staffing arrangements were consistent as records were not always maintained to demonstrate this. However, people and visitors told us they could usually access staff when they needed to. Recruitment checks were completed as required to ensure staff were deemed suitable and safe to work with people.

Staff described an open culture where diversity was recognised and supported. Staff said management staff were accessible if they needed them. Staff felt able to speak up if needed and felt they were listened to.

Communication across the service was effective because a small team of staff worked together and they used electronic communication apps to keep in touch with one another regularly.