Honeybourne House

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.

We identified 1 breach of legal regulations.

People were not always supported to have maximum choice and control of their lives and staff did not fully understand their roles and responsibilities under the Mental Capacity Act 2005 (MCA) including Deprivation of Liberty Safeguards (DoLS). However, the provider had systems and processes in place to help ensure people were supported to understand their rights and staff had received training in MCA and DoLS.

We have asked the provider for an action plan in response to the concerns found at this assessment.

We identified 1 breach of legal regulations.

Systems were either not embedded into practice or undertaken robustly enough to identify and monitor the quality of the service and effectively drive improvements. This meant systems operated by the provider had failed to identify concerns and shortfalls we found during this assessment and could not be relied upon as a source to measure quality and risk. Issues included concerns with regards to safeguarding, person centred care, staffing levels, management of risk, MCA, DoLS, and the environment.

However, people who were able to share their views with us and their relatives spoke positively about the service, the staff and the care and support they received. We saw action taken by the new manager was having a positive impact on the care and support people received, as well as assurance checks and audits, but needed time to be embedded into practice. The manager had a clear vision for the service and described how they were developing good working relationships with other health and social care professionals which meant advice and support could be accessed as required. Throughout the assessment, the manager was open with us, acknowledged any areas for improvement and was keen to put processes in place to address any areas of concern.

We have asked the provider for an action plan in response to the concerns found at this assessment.