Aston 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

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 requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment/ and staffing.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

During the assessment, we raised several concerns relating to safety and asked the provider to complete their own checks. Whilst some issues were addressed promptly; implementation and learning was inconsistent. For example, we saw people’s bedrooms being redecorated which was positive. However, despite CQC raising with the Nominate Individual our concerns around care planning and the same management of medicines, we were not assured sufficient improvements had been made.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Emergency grab sheets containing information to support safe transitions between services were not robust. The essential information included was inconsistent and did not always reflect people’s current needs. This meant there was a risk people would not receive safe continuity of care in a person-centred way.

We reviewed care plans and risk assessments, and we found some known risks were not assessed, recognised and monitored. When risk assessments specified support needed, this has not always been followed. This placed people at risk of receiving unsafe and/or unsuitable care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

There were systems in place to report safeguarding concerns when they had been identified. Staff described how they would recognise signs of discrimination and abuse. They knew how to report concerns; however, there was a confusion regarding people’s capacities and positive risk taking. For example, one person was at a specific risk, but they were awaiting a mental capacity assessment. We saw the provider did not follow the person’s risk assessment and did not wait for the assessment outcome before removing authorised restrictions which could potentially result in the person being harmed.

Staff had completed e‑learning training on the Mental Capacity Act; however, their practice demonstrated, they did not fully understand the principles or how to apply them. This lack of understanding contributed to decisions being made without appropriate capacity assessments or best‑interests processes, placing people at risk of having their rights overlooked.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments for associated risks were not always in place, robust or current to reflect the care people required. These included risks associated with suicide, arson or sexual exploitation. This posed people at risk as staff had no appropriate guidance to keep people safe.

Some people required hourly observation charts to keep them safe and there were unexplained gaps in the monitoring of these risks. Guidance for staff in people’s risk assessments were not always followed by staff. For example, 1 person was supposed to be assisted when accessing the community over a specific distance. We saw multiple instances when the person was not assisted by staff and going further than just a local shop. This posed a risk to the person’s health and well-being.

Another person’s care plan stated staff were expected to complete a dynamic risk assessment before the person left the premises. However, there was no evidence of dynamic risk assessment taking place and the person being risk assessed before leaving the premises. This meant staff were not following the person’s care plan and not always assessing risks which could potentially place the person at harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the first day of our inspection, we found the evacuation list contained a name of the person who passed away in November, and 2 newly admitted people were not on the list. There were 2 grab bags at the service. The grab bag stored in the staff sleeping room had no Personal Emergency Evacuation Plans (PEEPs) and the grab bag stored at the office had PEEPs for only 2 people. We drew the registered provider’s attention to the inconsistent information and how in the event of an emergency, there was a risk people might not be evacuated safely. The registered provider acted upon our feedback and updated the evacuation list and printed out people’s PEEPs and placed them in the grab bag in the office. However, people’s PEEPs did not always reflect people’s specific conditions. The laundry fire door was propped open with a laundry basket; one person’s bedroom door was wedged open.

During our visit we saw refurbishment taking place at the service and bedrooms being re-decorated and improved to meet the service users’ needs.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People told us staffing levels could be improved during weekends. One person told us, “They could do with a few more (staff) so that I can do more activities. The weekend is quiet anyway but could do with more (staff)”. Another person said, “Could be more (staff) at weekends”.

There were mostly 3 carers covering the morning shift and 2 carers covering the afternoon shift. However, during weekends sometimes staffing levels dropped to 2 carers in the morning. According to the provider’s policy 2 carers were required to administer medicines, which meant sometimes there was no staff to check on people, because both staff members were busy administering medicines.

One person’s daily notes mentioned the person asked to be assisted with outings by a member of staff as per their care plan and risk assessment. However, there was no staff available to assist the person and they had to travel to the town centre on their own, which contradicted their care plan and risk assessment.

Staff were not always appropriately trained and knowledgeable of people’s needs. Staff’s understanding of their responsibilities regarding MCA 2005 was poor. Staff told us they had received no training in how to complete people’s care plans and risk assessments. However, each member of staff was responsible for reviewing 2 people’s care plans and risk assessments which resulted in poor quality care plans and risk assessments. This meant care plans and risks assessments lacked the necessary information to care and support people appropriately.

Some staff told us they had not received training in people’s specific mental health needs, which contradicted their training matrix. The care records reviewed lacked details about people's specific mental health conditions and the management of these, which questions the quality of training provided to staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and staff had access to personal protective equipment. Some redecoration had also been completed. Some parts of the building still required redecoration and refurbishment, however this was ongoing and a refurbishment plan was in place, with timescales for completion of works. Suitable policies were in place, and staff had completed training in infection prevention control.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

When people were prescribed ‘when required’ (PRN) medicines there was not always person-centred information to support staff to safely administer the medicines. This meant people might not get the ‘when required’ medicine when they needed it. We found when people were prescribed a medicine with an option to give 1 or 2 tablets, there was not always information to support staff to know which dose to give. There was a risk people might not be given the most appropriate dose. There was no detailed information on signs and symptoms which would require medicines to be administered, no information about predictable side effects or guidance on the next action to take if PRN medication does not have desired effect.

Medicines were stored safely and stock levels recorded correctly. Fire risk assessments had been completed for people who had emollient creams applied. There were effective systems in place to order, store and dispose of medicines.