Albemarle Hall 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 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 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.

The service promoted a culture of openness, learning and improvement. Incidents and accidents were reviewed to identify if any lessons were learnt or if changes were needed. Care plans were promptly reviewed and updated to reflect learning. For example, following an incident where a person exhibited resistance to personal care, the individual’s care plan was revised to include detailed guidance for staff. This included specific strategies to reduce the person’s stress.

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.

People experienced safe care, with effective systems for managing risks and transitions. People’s needs were thoroughly assessed before moving into the service. Where possible, people and their families were involved in planning transitions between services. Referrals to other professionals were made in a timely way.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The provider shared concerns quickly and appropriately.

People were protected from abuse, neglect, and discrimination. People raised no concerns about their safety. Staff had completed safeguarding training and knew how to report abuse and were confident to do so. Safeguarding policies were in place. When concerns were suspected the management team made referrals to the local authority in order to keep people safe. Deprivation of Liberty Safeguards (DoLS) applications were made and monitored.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were safe from avoidable harm as the provider had risk assessments and care plans in place to manage risks. Risk assessments were completed across a wide range of areas and included detailed guidance on how to mitigate identified risks and promote safety. Staff had completed training around the management of risks including choking, diabetes and moving and handling. Staff used safe moving and handling techniques and ensured people were reassured and involved throughout. Pressure reliving mattresses that were not always correctly set to align with people’s weight. We raised this with the provider who ensured a process was implemented to address this. Staff demonstrated an understanding of people’s needs and the actions required to maintain their safety.

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.

A radiator in an ensuite was uncovered and hot to the touch putting people at the risk of injury from contact with a hot surface. Hot water temperatures were being checked daily. However, some were being recorded above the safe maximum level putting people and staff at risk of scalds. Following us raising the concerns with the management team they acted immediately to mitigate these risks. Equipment and the premises were serviced and monitored as required. There was a home development plan in place to further improve the premises.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were supported by enough skilled staff to meet their needs safely and effectively. We observed staff responding quickly to people’s needs. People and staff felt staffing levels were adequate. Staff felt supported and received an induction and regular supervisions and appraisals. Staff were required to participate in routine observed practice sessions in key areas such as assisting people with eating and safe moving and handling. These observations helped ensure staff competency. People were supported by staff who had been safely recruited. Staff had received training specifically in regard to the people they supported. For example, staff had received training around dementia, dysphagia, epilepsy awareness and Multiple Sclerosis awareness.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People could not be assured they were protected from communicable illnesses as staff did not always follow safe practices effectively. For example, the underside of some continence equipment was visibly unclean. Whilst the kitchen was visibly clean and generally well maintained, effective food hygiene practices were not consistently followed. During our inspection we observed unlabelled food items in the fridge and some opened products that had exceeded safe storage durations and were spoiled.

However, overall, the home was clean and tidy. There were good supplies of personal protective equipment throughout the home.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People received their medicines safely and as prescribed. Staff had received training and their competency was assessed. We observed the clinic room where medicines were stored was locked. However, the keys to the fridge and homely remedies cupboards were in the locks within the medicine room. Following our assessment the registered manager assured us that this is not usual practice and improvements would be made. We observed medicines being administered safely.