Harborne Lane Nursing Home

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed.

Risk assessments and care plans did not always contain sufficient, up to date information to keep people safe. Safeguarding referrals were not always made when there were concerns about potential abuse or neglect. Improvements were required to ensure accidents, incidents and allegations of abuse were clearly documented, reviewed, investigated, and analysed to identify trends and reduce the risk of them happening again. Lessons learned were not always shared with staff. Improvements were needed to medicine management. Some covert medicine plans did not follow NICE guidance or evidence the Mental Capacity Act 2005 had been followed. We observed the medicines trolley was not always locked when it was left unattended while staff administered medicines in service user’s bedrooms.

This left people at risk of avoidable harm and was a breach of regulation 12 safe care and treatment.

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

People did not always receive support in accordance with the requirements of the Deprivation of Liberty Safeguards (DoLS) associated code of practice. This was a breach of regulation 13 safeguarding service users from abuse and improper treatment.

People did not always receive support in accordance with the requirements of the Mental Capacity Act 2005. This was a breach of breach of Regulation 11 need for consent.

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

People did not always receive support in line with their needs, this was a breach of regulation 9-person centred care.

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Quality assurance systems had failed to identify many of the concerns raised by our assessment. The provider was in breach of regulation 17 good governance.