Advent 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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to person centred care and safe care and treatment.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not a consistent positive culture of learning at the service. Although staff completed accident and incident reports, these were not completed fully, and not all staff were debriefed following difficult incidents. Information about how incidents were dealt with and techniques used were not always recorded. We also received feedback from staff that they did not feel supported after incidents. We reviewed the provider’s incident log and this did not clarify how these were analysed and managed to reduce future risk. Even though areas of learning were recognised, appropriate care documents were not always updated to reflect learning and reduce risk of recurrence. We reviewed the provider’s complaints log, although learning was identified from those complaints noted on the log, we received feedback from relatives that they had previously shared concerns with the manager and no action had been taken. The provider could not evidence these concerns were logged and any action taken.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Information was available to support people needing to access health care facilities.

Clear processes where not always in place to protect people from abuse. We reviewed one person’s positive behavioural support (PBS) which is a recognised proactive support framework for people who find it difficult to communicate their anxieties aiming to improve their quality of life. The PBS plan advised staff to remove items from a person when they displayed periods of agitation, and there was use of physical restraints without any evidence of professional involvement as outlined in the providers positive behaviour support policy. Even though staff had completed relevant training to complete the restraints identified in the PBS plan, the registered manager informed us they were not aware physical restraints were being completed by staff. We reviewed incident reports for the person who had a PBS plan. It was clear the PBS plan was not always being followed as advised. Upon review of the persons care documents, it was not clear whether the provider had completed a risk assessment around the use of restraints to reduce the likelihood of any injuries occurring.

The provider did not always understand and manage potential risks to people. Staff did not always provide safe care to people to meet their needs. The service provided care and support to people who displayed periods of agitation in different forms. We received consistent feedback from staff that they did not feel safe to deal with challenges and they felt this left people at risk. Upon review of documents, we found a positive behavioural support plan had not been completed by an appropriate professional, this meant the person was not supported to manage their risks appropriately and safely. Inappropriate techniques were being used to try and reduce the persons agitation and there was no review of this document to evaluate it was effective or needed adjusting. Staff also reported they did not feel there was enough staff to safely support people, staff described examples of when they felt some people were unsafe when they were dealing with challenges displayed by other people.

The provider did not always detect and control potential risks in the care environment to support the delivery of safe care. Some people had bed rails in situ. The provider had not completed a risk assessment for the use of bed rails and bed rail checks were not being completed. The provider had detected and controlled other potential risks in the environment. There was a process in place to ensure maintenance checks of the environment and equipment were completed.

The service did not always deploy staff effectively at the service to meet people’s needs. The service provided agreed levels of commissioned hours for each person they cared for. Although these were included on the rota, it was not evident that the hours were used effectively to meet people’s needs. We received consistent feedback from staff and relatives that there was not always enough staff to support them with any activities they wanted to do. One staff member said, “We have a person who has their own car, they love to go out in it and it's in their support plan that this is what they enjoy, but due to the fact we are so short staffed we do not get to take them out very much.” We also received feedback form staff that at times people were left waiting for care or other support as a result of staff not being deployed efficiently at the service. One staff member told us they could not always leave the house as they were needed to support others in the house, for example if they required 2-1. Supervisions were being completed, but these were not consistent. Sometimes staff only had 1 one-to-one supervision in the year. We reviewed completion of training for the service. The service had recorded that competencies was at 100% but during our site visits, it was identified that not all staff had a medication competency completed. As well as this, we also queried the completion for medication competencies but the provider could not demonstrate that they were completed appropriately. We received feedback that staff did not always feel confident to complete some tasks after the training they had completed and would have benefited from additional support, but this was not always provided. The provider had completed pre-employment checks for the staff at the service.

The provider did not always assess and manage the risk of infection. During our visits, we found bathrooms did not always have handwash and paper towels available. We also observed infectious waste bins to be open in the grounds of the service; however, the service was clean throughout including people’s rooms and communal areas.

Medicines were not always managed safely. Medication protocols for as and when required medication did not hold up to date information which was misleading for staff, we raised this with the manager and asked them to seek medical clarification on how the medication should be administered. Changes to people’s behaviours had also not been considered in the medication protocols, as the medication was being administered more frequently, it was not taken into account the medicine will need to be replenished sooner. A service user was left without medicine for 1 day used to reduce their agitation when it should have been administered. Where people required their bowels to be monitored, this was also not being completed in line with their medicine protocols. Where there were missing signatures in people’s medication records, there was no explanation for why this was. Prescribed ointments were not signed for when applied on people. Temperature checks were not being completed of the fridge or the room where medication was being stored. Staff were also not consistently checking a person’s PH level of their stomach acid.