Albany House - Doncaster

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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 learnt to continually identify and embed good practice. Accidents and incidents were reviewed and analysed by the management team. Appropriate actions were taken following analysis and lessons learned were identified, shared and implemented with the staff team to ensure continuous service improvement.

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 packs about people’s care and support needs were available when people went into hospital which ensured continuity of care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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. Safeguarding concerns were shared quickly and appropriately. People who lived in Albany House – Doncaster told us they felt safe. One person said, “Without a doubt I am safe. [Members of staff] make sure they are stood by my side when I am stood up and watch so I don’t fall.” Another person told us, “Yes, I am safe here. [Members of staff] look after me well.” The provider had policies and processes in place to keep people safe and members of staff had attended training course so they knew how to report any concerns about people’s safety.

We saw evidence the provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care plans were person-centred and described how people preferred their care and support to be delivered. An assessment of people’s needs identified and mitigated risks appropriately so care could be provided safely. Care was delivered safely in line with peoples’ care plans.

The provider did not always detect and control potential risks in the care environment. They did make sure equipment, facilities and technology supported the delivery of safe care. The provider monitored risks associated with the care home environment, however, we found some radiators in communal lounges, corridors and bedrooms were very hot to the touch and some wardrobes were not fixed to the walls. This represented a risk to people’s safety. We raised these concerns with the registered manager who took immediate action to reduce the risk. Following the site visit, we received assurance the provider had taken additional steps to mitigate the risk associated with the concerns we identified. Fixed temperature thermostatic valves were fitted to radiators and all wardrobes were fixed to walls. The registered manager had put in additional governance checks to be completed by the management team at the start of each shift and learning sessions had been put in place for members of staff through team meetings. The additional governance checks needed to be sustained and embedded to ensure the care environment was consistently safe for people. One person told us, “[Members of staff] are always around cleaning. They found some damp on my wall a few weeks ago. They have treated it and I have a dehumidifier drying it out. It is very warm in here. There is a maintenance man.” A relative told us, “[The care home environment] is fantastic, [family member] can go into their room or into the lounge.”

The provider made sure there were qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care which met people’s individual needs. Staff were deployed effectively throughout the care home to provide safe care and support. Members of staff were recruited safely and they received regular supervision and training relevant to their roles. We spoke with the registered manager about processes in place to ensure regular employment safety checks were carried out in line with organisational policies. There was a mixed response from people about the availability of members of staff. One person told us, “I think they could do with more staff. They are run off their feet at times. There are lots of different staff, I see the same faces.” A relative told us, “There is always somebody around. [People] are not left alone in the lounge; there is always 1 or 2 members of staff with people.” Another person told us, “[Staff] are very kind, that is what I like the best in here.”

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 care environment was clean and odour free. There were stores of personal protective equipment (PPE) throughout the care home. Members of staff had received training to minimise the risk of infection and how to use PPE effectively.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Members of staff involved people in planning, including when changes happened. The administration of medicines was managed safely and members of staff received appropriate training and support to ensure safe administration processes were followed. However, we identified some protocols for ‘as and when’ medication were missing. We raised this with the registered manager and they took immediate action and protocols were put in place whilst we were on-site. Following our site visit, the provider carried out a medication audit to ensure protocols were in place for all ‘as and when’ medications. Learning from the inspection and review of medication processes needed to be embedded and sustained in the service.