Ailwyn Hall

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

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. The service was in breach of legal regulations in relation to safe care and treatment; people’s medicines management and staffing. Staff did not always have the experience and knowledge to fulfil their job role and there was not always a clear assessment of their competency being assessed. There was an insufficient deployment of staff to meet the needs of people in the service safely.

This service scored 38 (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 effectively operate a learning culture. We were not assured from the service’s processes that the actions taken were effective. They were reactive responses and did not always reduce the risk appropriately. Low level concerns were not always addressed and investigated, we spoke to the management team about this, and they implemented measures to address this shortfall. The service had implemented lessons learnt following safety incidents, but we noted these were not embedded. However, relatives we spoke with felt safety concerns were dealt with appropriately and actions taken by the service to reduce them from reoccurring. One relative we spoke with said “they have put a crash mat next to her bed so if she steps on it, they will be alerted. That’s a great idea. I can relax knowing that people are there for her”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. We spoke to relatives, and they felt that people living in the service had referrals that were submitted in a timely manner and healthcare professionals who worked alongside the service echoed this, however, we were not assured safe systems were always followed. Pre-admission assessments were not always safe, and the service did not raise appropriate referrals when incidents were identified to prevent them from reoccurring. We spoke to the management team about this, and they raised safeguarding referrals retrospectively.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately. The service did not actively protect people from risk of harm or abuse. We identified several safeguarding concerns throughout our assessment that the service had failed to identify. Initially when we made the service aware of these concerns, they did not act promptly to address them. We then escalated the concerns, and we were sent assurances about the action they had taken. The management team conducted mental capacity assessments and these were robust assessments. However, people living in the service did not have individual risks assessed and this put them at risk of harm. All relatives that we spoke with felt people were safe in the service, however we identified shortfalls in staff knowledge around the signs of abuse. One staff member we spoke with, when we asked them about the different signs of abuse, they said “Physical, verbal, is definite. Other than them I can’t really think of any others.” There was a lack of understanding with the staff around Deprivation of Liberty Safeguards (DoLS) and how it impacted people in the service, however the management team were proactive in ensuring DoLS assessments were applied for and routinely followed up outstanding applications. We observed staff failed to de-escalate situations appropriately and this continued to put people at risk of harm.

The provider did not always manage risks to ensure people were safe. The staff had not fully assessed all the risks people experienced. This meant these had not been planned for or mitigated. We reviewed several care plans, and we were not assured that the service identified risks fully However, we spoke to staff, and they informed us how they supported people to manage risks daily using communication and equipment provided. Relatives that we spoke with gave examples of actions implemented to help people within the service to manage risks.

The provider did not always detect and control potential risks in the care environment. They did not make sure that facilities, and technology supported the delivery of safe care. When we arrived at the service, we were not asked for our identification or to be signed in the entire day we were onsite. The environment was worn and needed to be redecorated in several areas. The provider had begun this in some areas, and we were told there was a maintenance plan in place. We found that people in the service had restricted access to suitable toileting facilities. Not all rooms had ensuite facilities and communal bathrooms and showers were locked. The provider had not thought of the least restrictive option when assessing the risks posed. When we spoke to management about the restriction imposed on people they removed the locks. An external door in the dining room that led to a secure garden was unalarmed and there were people in the service at risk of falls. There were historical concerns around doors being unalarmed. When we spoke to the management team about this, their initial actions had not fully assessed all the risks. However, they resolved this by the time we had completed our assessment. We reviewed maintenance checks carried out on the service, and these were completed. The service also conducted regular fire drills with the staff.

The provider did not make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support. They did not work together well to provide safe care that met people’s individual needs. However, the service had a new competency framework; however, this was yet to be fully implemented and had not fully assessed staff knowledge and the support they required. The service used the same agency provider where possible to ensure consistency and that people’s needs within the service were not compromised. The agency staff received an induction to familiarise themselves with the service. Relatives we spoke with had no concerns over the staffing levels. However, Staff felt there were not enough staff, and our observations identified there were not enough staff to meet the needs of people safely throughout the day or at night. People’s needs had not been assessed appropriately, resulting in the dependency tool being ineffective. The service added an additional staff member at night which assured us risk to people was lessened, however there were still concerns over people’s dependency needs and the staffing levels during the day. The service was supporting a lot of people with high support needs, some people had 1:1 support in place but there were still a lot of altercations between people living in the service and not enough staff to mitigate the risk. One staff member we spoke with said “I feel we could do with more staff” This continued to put people at risk of harm. Additionally, we reviewed the staff training matrix, and not all staff were competent in de-escalation techniques. We had concerns over staff experience and qualifications. Staff were not able to tell us how they would follow specific policies and procedures to keep people safe. We reviewed 4 staff records and there was adequate recruitment checks conducted on people. There was regular support and supervision.

The provider did not always ensure the prevention and control of infection. Relatives told us they had noted an unpleasant smell on occasions but felt this was always addressed promptly. We found there were unpleasant odours in the service. We discussed this with management. They took some action to resolve this but unpleasant odours were not fully eliminated. Every room had a cleaning schedule in place, and these were being completed appropriately and the service carried out a deep cleaning of an individual rooms once a month. We spoke to staff, and they felt they were provided with an adequate amount of personal protective equipment (PPE) to assist them in their role.

The provider did not ensure the safe management of medicines. We found 8 people living in the service had run out of important medicines over different dates, 7 of these people could have been at an increased risk of harm by not having their prescribed medicines. The provider’s own audits failed to identify this. Initially these concerns were not addressed appropriately when we informed the service of them. We reviewed the service’s policies and procedures which informed staff what to do when out-of-stock medicines occurred, and these procedures had not been followed. We spoke to staff about what actions they would take in the event of running out of medicines and they referred to informing management and not following the policy and procedure. We observed medicines trolleys being left unattended and unsecured. The services electronic medication application records (MAR) did not always synchronise so you could not see clearly if someone had, had their medication or not. Their processes were not robust, and no risk assessments were in place to manage this. Following our assessment, the service reviewed their connection issues and implemented an additional network router to address this shortfall. Relatives we spoke with did not have concerns over medicines management, they told us the provider had informed them of errors and action they had taken.