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Aldbourne Nursing Home

Overall: Good read more about inspection ratings

South Street, Aldbourne, Marlborough, Wiltshire, SN8 2DW (01672) 540919

Provided and run by:
Aldbourne Nursing Home Limited

Report from 6 February 2024 assessment

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Safe

Good

Updated 8 March 2024

We reviewed 3 quality statements for this key question. There were systems to keep people safe from abuse and harm. Staff told us they would not hesitate to raise any safeguarding concerns and were confident timely action would be taken. Risks were assessed, but records did not always show guidance had been followed to ensure safety. There were enough staff available to meet people’s needs.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning culture

Score: 3

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safe systems, pathways and transitions

Score: 3

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safeguarding

Score: 3

People told us they felt safe, and relatives had no concerns about safety. People and relatives told us they would raise any concerns if needed. They felt they would be listened to and anything they raised, would be addressed, and satisfactorily resolved.

Staff had applied to the local authority for DoLS authorisations. Two had been authorised but records did not always clearly demonstrate compliance with the DoLS condition. This was rectified by the end of the on-site visit. There were a range of detailed policies and procedures that were regularly reviewed. These were discussed with staff to ensure awareness and improve practice. Safeguarding formed part of the provider’s mandatory staff training programme and training specifically for leaders was being investigated.

Staff were aware of their responsibility to report safeguarding concerns. They were confident concerns raised would be managed appropriately by the management team. Leaders told us all staff received safeguarding training and there were additional workshops and regular discussions about safeguarding. Leaders told us people and relatives were supported to understand safeguarding and how to raise any concerns. This was through general conversation, information on notice boards and the service’s newsletter.

We observed people were comfortable and relaxed in their surroundings and with staff.

Involving people to manage risks

Score: 3

Staff were aware of the risks people faced and how to support them safely. Leaders told us they encouraged positive risk taking, which was managed in a person-centred way for each individual. Preventative measures to mitigate risk were discussed with the person and their family or representatives.

People were consulted about any risks they faced. They said they had the right equipment and staff were aware of their needs, which enhanced their safety.

Systems were in place to manage risks safely. However, we reviewed one person’s records did record how they must be repositioned, and the required frequency, to minimise their risk of developing a pressure sore. During our on-site visit, this had been investigated and improvements had been made. Staff received a debrief and lessons learnt exercise, after any incident. This minimised a reoccurrence and ensured on-going development.

We observed people being supported safely by staff who knew them well. We heard one person received advice about posture from a physiotherapist whilst having their walking frame adjusted. This minimised the risk of the person falling.

Safe environments

Score: 3

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safe and effective staffing

Score: 3

People and relatives told us there were enough staff available. They said there were always staff around and all except one person told us call bells were answered promptly. Leaders were aware of this and had staggered staff’s break times better, to avoid such waiting.

We observed the atmosphere of the home was calm and relaxed. Staff were going about their work without rushing, taking time to talk to people and relatives. People’s support was delivered in a timely way.

The provider had up to date recruitment policies. However, the procedure for the recruitment of volunteers had not been followed. Whilst the majority of volunteers were known to the service, the informal process used did not ensure safety. Leaders reviewed the entire process for recruiting volunteers after our on-site visit. Staff had been recruited safely, as all pre-employment checks had been carried out prior to them starting work. There was mandatory training and designated champions, who cascaded additional learning to others. Staff received a 6 monthly review and supervision through informal discussions with leaders. More formal supervision was available on request and when performance improvement plans were needed.

Staff told us there were enough staff on duty. They said could work extra to cover staff sickness, but if this was not possible, agency staff were used. Staff told us they felt valued and very well supported. They said they received regular training and discussed topics in handover meetings. This enabled them to do their job effectively. Leaders told us they used a dependency tool, but also used observation and staff feedback to determine staffing levels. They said they had autonomy to flexibly manage staffing requirements and had stopped admissions until more staff were recruited. Leaders told us there was a focus on training and support was informal through regular catch ups and discussions.

Infection prevention and control

Score: 3

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines optimisation

Score: 3

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.