Haddon House Nursing Home

This assessment was carried out due to risk shared by partner agencies, and the age of the previous rating. This assessment was carried out over 2 site visits. Following our first site visit, the provider told us the actions they would take to address concerns identified. We followed up on these actions the following week. This enabled us to assess their response and whether actions had been implemented.

We identified breaches in regulation in relation to safe care and treatment and good governance.

The service was not well-led. There were significant shortfalls in leadership and oversight. Systems to monitor risk and drive improvements were not effective. Actions to address safety concerns identified by the provider, stakeholders and CQC had not always been taken. There was a poor culture within the service, whereby staff and leaders did not always demonstrate accountability. This placed people at risk of unsafe care.

Risks and key information were not always communicated effectively between staff teams.

Systems to monitor people’s care and outcomes were not always effective, such as wound monitoring. Improvements were needed to ensure healthcare professional recommendations were consistently recorded within care plans. For example, details regarding modified texture diets were not always accurate. This placed people at receiving care which did not meet their needs.

Medicines were not managed safely. There was excessive levels of stock, and out of date medicines within the service. The storage, disposal and oversight of medicines was not in line with the provider’s policies or procedures. People were not always supported to maintain their skin integrity. Care records provided inconsistent guidance to support pressure care, and did not demonstrate people had been consistently repositioned for pressure relief. Staff were not deployed effectively, and communal spaces were not always supervised. Staff had not received regular supervisions to support in their wellbeing or development. Lessons were not always learned when things went wrong, as actions were not always taken to improve safety. People did not always have the appropriate equipment in place to support them safely. This placed people at risk of harm. We identified potential safeguarding concerns and restrictive practice which had not been promptly identified and escalated prior to our assessment.

The provider had already begun to implement changes to leadership arrangements following identified shortfalls. These changes were in progress at the time of our assessment.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.