Archived: Alston View Nursing and Residential 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 that 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.

The service was in breach of the legal regulations in relation to safe care and treatment and staffing.

This service scored 41 (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 learnt to continually identify and embed good practice, or to reduce the risk of mistakes re-occurring.

Staff completed incident forms which were uploaded to the electronic system. However, not enough action was taken to review the incidents and make improvements to care and treatment. For example, incident reports recorded for 1 person showed they had experienced several falls and incidents in the weeks prior to the assessment; 1 of the falls resulted in the person being admitted to hospital. However, no immediate measures were taken to identify or address to minimise the risk of incidents being repeated.

A relative told us, “I am not sure this is the right home for my [my relative]. They have had some problems with other residents and the home didn't appear to deal with the issues.” Following our feedback, the provider updated care plans and made changes to care and treatment.

Staff worked with people and healthcare partners to establish and maintain safe systems of care, although some improvements were required.

The manager and staff made referrals to external agencies and shared information effectively. However, we were not assured there was an effective admissions process to make sure that staff had all the right information about a person when they first moved into the home. The provider had admitted people into the service that on reflection, they may not have done so as there were challenges in meeting some assessed needs. Following our feedback the provider told us they would update their pre-admission assessment and review processes with the local authority to make sure thorough and up to date information was collated.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We found instances of repeated incidents where altercations between people had not been managed well, leaving people at risk of harm. However, there were appropriate policies and procedures, and staff completed safeguarding training. The provider made referrals to the local authority when concerns arose and collated information.

The provider did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although the provider conducted assessments and reviewed care plans regularly, we found this did not always mitigate risks to people’s health and wellbeing. Some people’s care plans stated that continuous monitoring was required to meet their needs effectively, however this was not always possible due to other pressures on staff. We observed 1 person becoming distressed on a regular basis throughout the day. Staff responded when they could which was effective at easing the distress. However, due to other pressures, it was difficult for staff to respond in a timely way, or to undertake preventative measures. We observed another person that wandered regularly, and staff were unable to provide a high level of monitoring to reduce the assessed risks regarding picking up food items and other items that could pose a risk. A family member said, “I worry about the staff’s understanding of [specific health condition] and caring for a resident with this health condition.”

Following our feedback, the provider took measures to address, including updating care plans.

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

During the inspection we found potential risks in the environment. The sluice cupboards, the electric cupboard and the laundry room were left unlocked with no staff in attendance. These rooms contained items which could pose a risk to people’s health and wellbeing.

We observed spillages on the floor in communal areas that had not been remedied by staff who were nearby, to reduce the risk of falls to people.

We observed a large crack in a person’s bedroom window which had not been identified as needing a replacement.

However, the provider had conducted health and safety checks and were compliant for example around fire safety, gas and electrical safety.

Following our feedback actions were taken to improve the safety of the environment including a replacement window.

The provider did not make sure there were enough qualified, skilled and experienced staff.

There was not enough staff to meet the needs of people safely and effectively. A high number of people were assessed as being ‘very high dependency’. Several people required a high level of close supervision or monitoring, and some people required 2 staff for moving and handling support. We found that staff could not respond to people’s risks in a timely manner due to operational pressures and did not have enough time to predict and act accordingly for people who were experiencing distress, as per their care plans.

The provider had requested extra funding from the local authority on more than 1 occasion, but this had been declined. However, they had not arranged for alternative measures to address the risk to people. A person told us, “I stay in my room, and it would be nice to have company sometimes, but the staff are very busy.” A relative said, “There are lots of people needing a lot of care and I just don't think there is enough staff to cope.” A further relative said, “I feel the care is basic because staff have not got the time to give the extra care. The staff are very willing but can’t do everything.”

Following our feedback the provider arranged an extra member of staff to support them to meet people’s needs more effectively. Additionally, the local authority commissioned continuous support for someone who was waiting for a more appropriate care provision.

The provider recruited staff using effective processes and made the relevant safety checks. Staff completed relevant training to their roles.

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.

There were dedicated cleaning and domestic staff, and regular cleaning schedules and checklists were in place. We observed the home to be clean and tidy. Staff cleaned people’s rooms every morning and when required.

However, the communal area required refurbishment following recent leaks, this was scheduled to take place within the next few months.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Some records relating to the safe administration of medicines needed improvement. Three medicines records showed duplicate doses of medicines administered, however, staff recognised this was incorrect information provided by the pharmacy and the person did not receive an incorrect dose. We saw another record where a discontinued medicine was still listed.

We identified gaps in the records for the application of creams and for enteral feeds and fluids (tube feeds). A self-administration risk assessment was not in place for 1 person who managed their own inhalers to help ensure that they would receive any support they might need. We saw 3 records where people had missed doses of medicine as there were none left to give. This meant we were not assured that people received their medicines according to their care plans and put them at potential risk of harm.

Medicines audits were regularly carried out by the home’s management team, and an improvement plan was in place but some of the shortfalls found at our visit had not been identified.

Some staff had not been assessed as competent in handling controlled drugs, however staff completed medicines training.

The local GP practice carried out a ‘ward round’ at the home every week where people’s health needs and medicines could be reviewed. Appropriate arrangements were in place for the covert (hidden) administration of medications if needed. Medicines including controlled drugs were stored safely, although creams were not stored securely in people rooms.