Adalena 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 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 staffing.

This service scored 56 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons

were not always learnt following events to drive improvement at the service and embed into good practice.

The registered manager told us that lessons learnt following safety events were informal, and that investigations, although held, were not always recorded. Staff told us that reflection took place following events and that information was shared with them verbally following events. Staff told us they felt confident to raise concerns around safety, and concerns would be listened to and acted upon by the registered manager.

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.

People had health passports in place. These were available in easy read format, and contained information around people’s health conditions, mobility, communication needs, diet, religious beliefs and their likes and dislikes. These were shared appropriately with others when people moved between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did not always share concerns quickly and appropriately.

The provider had failed to notify us in a timely manner about an incident in which a person experienced harm. The provider has now submitted a notification for this event. The provider had a safeguarding of vulnerable adults’ policy in place, but was not able to provide a policy in relation to the safeguarding of vulnerable children. However, staff told us that they had received training in the safeguarding of adults and children.

We saw staff treating people with kindness, and witnessed warm and compassionate interactions between staff and people. Staff were able to tell us about the different types of abuse and how to identify them. A member of staff told us, “Everyone has the right to live their life free from harm, abuse and neglect; it’s my job to make sure the people I care for are safe”. Staff knew how and who they could report abuse to. People were well presented, cared for andpraised staff highly.

The provider and registered manager did not always work well with people to understand and manage risks.

Two people had a diagnosis of epilepsy and had no seizure action plans in place. However, these people had not had any seizures for over a decade, and there was no evidence that

people had experienced any harm because of this.

The provider did not always support positive risk taking; peoples visits to a static caravan had stopped due to potential falls risk, rather than exploring options to reduce these risks.

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

There was no risk assessment for the safe use of a bed lever. However, the registered managertold us staff assessed this risk every day. During our inspection we saw a fire door propped

open, we were told that this had been considered and risk assessed, but we saw no evidence tosupport this. We found substances hazardous to health were not stored safely. The registered

manager took immediate action to secure hazardous substances during our visit. We saw no documented evidence that the provider had undertaken nighttime fire evacuation drills, despite a recommendation to do so in their fire risk assessment plan. Fire evacuation drills did not record the time taken to evacuate and had taken place when 50% or more of the people

were absent. Therefore we could not be assured of their effectiveness. One recorded fire drill was dated in the future, therefore we could not be assured of the accuracy of this

documentation. People’s emergency evacuation plans identified that people may becomedistressed or agitated during a fire evacuation, but lacked robust information on how to reassure people. We found no evidence that people had come to harm, and the registered manager assured us that action would be taken address these concerns. Health and safety assessments had been undertaken in in relation to gas, electric, water, and fire safety equipment testing, and the provider was compliant in these. The home was well maintained, and fire exits were clearly signed and free from obstacles. The registered manager told us that the provider was responsive to any recommendations which would improve the environment of the home.

The provider did not always make sure there were enough qualified, skilled and experiencedstaff on duty. They did not make sure that staff recruitment practices were safe. They did not

make sure staff received effective support and supervision.

The provider did not always ensure that there were enough staff on duty to provide safe careand treatment. Staff rotas did not always accurately reflect the staffing level at the home. Some

staff had completed waking shifts of a 29 hour duration with no identified breaks. We saw no documented evidence that staff received effective support and supervision.

We saw limited evidence to support that the provider had undertaken their own Enhanced Disclosure and Barring Service checks (DBS). DBS checks provide information including details

about convictions and cautions held on the Police National Computer. Checks on staff employment suitability had not always been completed. Some staff files were missing application forms, health questionnaires and references. Staff had not always received suitable training to reflect the support needs of people living at Adalena House. However, the registered manager resolved

some of our concerns immediately, and has assured us that our remaining concerns will be addressed.

Whilst there was no evidence to suggest that people had come to any harm, there were fundamental shortfalls in recruitment and staffing practices that had presented a range of risks to people and staff.

The provider managed the risk of infection. They did not always detect and controlthe risk of it spreading. They knew to share concerns with appropriate agencies promptly.

During the inspection visit we found one dish of unlabelled, undated and uncovered food in the fridge at thehome. The registered manager told us this was from the previous day’s evening meal. Thismeant that people were put at increased risk of harm from the unsafe storage of food. The registered manager removed this immediately when identified.

Staff were trained in infection prevention and control and food hygiene, and were able to tell usabout the appropriate safe use and storage of food, and infection prevention control

measures.

Although we did not see staff wearing personal protective equipment (PPE) during our visit, stafftold us when they wore it, and were able to tell is about the differing levels of appropriate PPE

and when to wear it. Staff told us that PPE was readily available to them.

The provider did not always make sure that medicines and treatments were stored, managedand administered safely. Staff did not always record medications in line with best practice and

current guidance.

During our visit we found creams were not stored securely. However, the registered manager addressed this concern immediately. The registered manager told us that no formal audit of

medications were undertaken. They said no temperature checks on the safe storage of medications were completed. One person was using an over the counter purchased cream,

rather than their prescribed cream. The home had a stock of homely remedies; however, these were shared between people and no running count was kept. Protocols that were in place for

people’s PRN (as needed) medications lacked person centred guidance.