Alt Park Nursing 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

At the last assessment, the provider was in breach of legal regulations in relation to people’s safe care and treatment. At this assessment, not enough improvement had been made,and the service remained in breach of the legal regulation in relation to safe care and treatment.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. We were not assured with the robustness of accident and incident monitoring systems, as we found not all incidents were analysed. This included incidents where people experienced emotional distress and expressed this physically towards others. This meant there were missed opportunities to identify where action could be taken to reduce the risk of recurrence and avoidable harm.

The provider did not always manage or monitor people’s safety to maintain safe systems of care. Our review of people’s care plans found the effectiveness of the monitoring processes was not always well managed to keep people safe. For example, we found missing and inconsistent information within people’scare plans such as inconsistencies regarding a person’s fluid target and missing information relating to equipment a person required to reduce skin related risks. This increased the risk of people’s needs not being effectively met.

We were assured the provider completed assessments before people moved into the home to ensure they could meet their needs and individual risks. Visiting health professionals were positive about how the provider worked with them. Comments included, “There were some concerns regarding the quality of the care plans on the electronic care planning system,but the deputy manager was very pro-active during my visit and did action my recommendations.”

Safeguarding processes were not always effective. Although the provider and staff could confidently tell us the action they would take to protect people from potential abuse, we found this was not always done in practice. For example, we were not assured staff had raised concerns or safeguarding alerts in relation to concerns with people’s personal hygiene needs not being met and neglectful practice in relation to the cleanliness of their living environment.

A process was in place to record and monitor safeguarding referrals the provider had reported to the local authority safeguarding team. However, we found these records were not always well maintained. Further improvements to record keeping was required to ensure effective oversight of safeguarding investigations.

We were assured effective processes were in place to legally deprive people of the liberty to ensure their safety.

The provider did not always work well with people to understand and manage all risks. Staff did not always provide care to meet people’s needs safely and effectively. People’s care records did not always show risks relating to skin integrity were monitored and mitigated. For example,where people had active skin injuries, we identified the plans in place to treat the wounds were not always followed. This increased the risk of further deterioration and poor health outcomes.

We found some evidence of good practice in relation to falls prevention measures. The provider demonstrated how they had been proactive in escalating their concerns when people experienced recurrent falls and took action to ensure one to one care was put in place to keep people safe. We saw this had a positive impact on reducing the number of falls people experienced.

The provider did not always detect and control potential risks in the care environment. For example, we found environmental risks such as several fire doors that would not be effective in preventing the spread of smoke during a fire, upturned thresholds in communal walkways that posed a trip hazard, broken furniture, holes in walls, and areas of damp and mould in people’s bedrooms.

We identified staff were not always alert to risks within the care environment. Our observations found people were mobile in the communal areas with unsafe footwear which increased the risk of falls. We observed jugs containing drinks made up to a normal consistency were located next to a person who had been assessed as requiring thickened fluids due to choking risks. We observed the person reaching for the drinks, we had to alert staff to this risk as it had gone unnoticed.

The registered manager was receptive to our feedback and took action to improve the safety of the environment before we returned for the second day of the assessment. We observed work was already underway to ensure fire doors were compliant and we were assured this was taking place in a staged approach throughout the home.

The provider did not always make sure safe recruitment practices were followed. For 3 staff recently recruited, we found gaps in recruitment checks as the staff members conduct in previous care roles was not consistently verified. This meant the provider did not have the necessary assurances about the staff members conduct in all previous roles they held involving vulnerable people which did not equip them with all relevant information to assess if they were suitable for the role.

There were enough staff deployed to meet people’s basic care needs and where one to one care was required,we saw this was in place. Staff received a thorough induction when they first started in their roles, and they were up to date with training the provider deemed mandatory to ensure they had the necessary skills for the role. However,people and their relatives told us staff did not always have the skills needed to meet people’s social needs. They told us staff rarely sat and talked with people. A relative said, “They just leave family member sat there, as long as they don’t stand up,they just ignore them.” Our observations found staff were mostly task led in their approach and there were occasions when there was very limited interaction between staff and people. Through our observations and people’s feedback, we were not assured people’s social and wellbeing needs were consistently met.

The provider failed to ensure systems were operated effectively to assess and manage risks relating to infection prevention and control (IPC). We found significant and widespread concerns with the cleanliness of the environment such as communal areas, people’s bedrooms and the kitchen. The concerns included unclean walls, floors, doors, unclean equipment such as wheelchairs, stand aids and hoists and unclean handrails in communal walkways with multiple areas of chipped paintwork.

The systems in place to ensure the storage and disposal of PPE were not safe. We found unused PPE and unused clinical supplies were stored in unsanitary conditions. In addition,we found clinical waste was not stored securely. We found all external yellow clinical waste bins were not secured and found used gloves and PPE strewn across the floor. This exposed people to a risk of harm of infection spreading.

Following the first day of the assessment, we shared our concerns about the cleanliness of the environment with the local authority safeguarding and environmental health teams so support,and guidance could be provided to improve cleanliness standards. When we returned for the second day, we found significant improvements had been made in relation to the cleanliness of the home which reduced the overall risk to the people living there.

Medicines were not always managed safely.

We found topical medicines were not stored securely in 3 people’s bedrooms. The failure to lock medicines away increases the risk of medicines related harm to people, including those people living with dementia. We found temperature checks in people’s bedrooms were not always completed to ensure topical medicines were stored as per the manufacturers’ guidelines to ensure their efficiency.

The provider failed to maintain a clear audit trail for medicines that had been returned to the pharmacy for disposal. This meant we could not be assured the medicines were disposed of safely. In addition, we found several bags of medicines that were due to be returned to the pharmacy were not stored securely in line with best practice guidance.

For a person who was prescribed a medicine to control or restrain their behaviour, we found the reason for the medicine being given was not always documented. Care records did not show non-pharmacological methods had first been tried and we were therefore not assured this person's behaviour was not being controlled excessively or inappropriately. We found the remaining quantity of this medicine did not reconcile with the records of medicines given therefore, we had limited assurance medicines records provided an accurate reflection of the medicines support provided.

We did find safe practice was followed in relation to the covert administration of medicines. These are medicines that are administered in a disguised format without the knowledge or the consent of the person receiving them. This was done in the person’s best interest and in line with legal requirements.