Adelphi Residential Care Home

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 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 the legal regulation in relation to safe care and treatment.

This service scored 53 (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.

There were 2 systems in use for staff to record incidents which showed the same information, and we fed back to the provider the forms used did not allow for thorough information to be captured to properly analyse themes and trends. The registered manager monitored incidents and although we saw analysis of people’s falls for 2025, they had not been completed for the 6 weeks prior to the assessment at the beginning of 2026.

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.

There was a pre-admissions process, and the registered manager completed pre-admission assessments to make sure staff could meet people’s needs. The registered manager considered compatibility within the service so that admissions were managed smoothly. Information was shared with other services, for example when people were admitted to hospital. Referrals to health providers were made in a timely manner. Staff said they were informed about people’s needs during handovers and were given time to read care plans and risk assessments. A member of staff said, “It’s really all about learning about that person and what they like and dislike, and what is important to them.” Staff also spoke about speaking to relevant people including social workers to capture important information.

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.

There was no system to make sure legal processes were followed for people who were at risk of being deprived of their liberty. One person’s legal authorisation expired in 2023, and the renewal was not applied for until 2026. We fed this back and the registered manager told us of their plans to develop an effective system.

However, staff knew how to raise safeguarding concerns and completed safeguarding training. There was information about safeguarding available to staff and the provider had an up-to-date policy. Everyone we spoke with said they felt safe; a person said, “I couldn't be safer. I don't feel under pressure, everything is lovely and calm.”

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.

Risk assessments had been undertaken however the ones we saw were completed between 2 and 4 years ago. Although staff signed to say they reviewed them monthly, it was not clear whether information was up to date on all occasions. For 1 person we did not see any monthly review signatures. For another person, although there was a choking care plan with relevant information about how to support, there was no choking risk assessment, and this person required a modified diet to manage risks. Some risk assessments did not contain thorough information, for example 1 person’s epilepsy care plan did not contain detail about signs and symptoms for staff to be aware of. However, for 1 person who experienced periods of distress, there was a thorough risk assessment and staff had good knowledge about how to support them.

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

There was no governance system to make sure risks were identified or acted upon in a timely manner and we found areas of concern regarding the premises during the assessment. Several upstairs windows did not have window restrictors, posing a risk to people. For other ‘sash’ windows, the mechanism to open them had broken and the restrictors on these were not fit for purpose. Some broken items had not been replaced or fixed such as a handrail in a person’s bedroom, and wardrobes were not secured to the wall. The laundry and sluice area was not secure, and we found keys had been left in the cupboard storing cleaning products. There was a fire escape leading from the lower ground floor to a communal area which was a steep winding staircase. This was blocked by a low-level gate in the communal area, which posed a falls risk. Fire risk assessments had been completed however there was no action plan to address identified concerns, and some tasks had not been completed to improve fire safety. We did not find any evidence of harm and the provider assured us action would be taken straight away to address.

Health and safety assessments had been undertaken regarding gas, electrical and water safety testing and the provider were compliant.

The provider did not always make sure recruitment processes were safe. There were enough qualified, skilled and experienced staff worked together to provide safe care that met people’s individual needs. Staff received support, supervision and development.

Although recruitment files showed that leaders made safety checks such as references and Disclosure and Barring Service (DBS) checks, DBS checks were not routinely re-checked after several years, which the provider’s policy recommended. DBS checks provide information including details about convictions and cautions held on the Police National Computer. For long standing members of staff, documents such as ID and proof of address had not been checked or risk assessed for. The provider did not indicate what action would be taken although ID and proof of address had been checked for newer members of staff.

There were enough staff to meet people’s needs, and compliance in relevant training to support staff knowledge and skills was high. Staff told us about the most recent training they completed which included face to face and online training. There was some usage of agency staff and agency profiles were in place to show what training had been undertaken.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The lower ground floor had a communal bathroom and due to limitations with plumbing this required a specific type of toilet system. We found a strong unpleasant odour in the bathroom. We were told this required regular cleaning to manage and was overdue. There were exposed pipes behind the toilet due to the need for regular access. The registered manager responded to our feedback to confirm this would be managed better and more frequently in the future. It was not clear how well-ventilated the bedrooms in the lower ground floor area were as the windows did not appear to be easy or safe to open, for example 1 bedroom had stained glass windows with no restrictors. The registered manager told us they could be opened to allow for ventilation. We observed some leaders not adhering to bare below the elbow guidance.

However, the rest of the home and bedrooms were clean and tidy with regular cleaning schedules in place. We observed staff wearing protective clothing such as aprons and gloves at appropriate times, and there was hand sanitizer available throughout the home.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There was appropriate information about people’s medicines and staff signed to say they administered medicines according to people’s prescriptions. Staff recorded when they administered time sensitive pain relief. Staff checked the temperature of the medicines room and fridge to make sure medicines were safe and effective to use. Staff recorded the dates that items such as creams and eye drops were opened so they were discarded when they expired. We saw appropriate risk assessments for example regarding flammable creams, and staff signed to say how much thickener they added to people's drinks.Drink thickener is added to drinks of people who are at risk of choking. However, we found the kitchen were the thickener was stored was unlocked. The registered manager told us someone was always in the kitchen to make sure no-one could accidentally ingest this medicine.