Alban House Residential Care 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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of the legal regulation relating to people’s safe care and treatment and staffing.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Records viewed did not consistently show there was a proactive culture regarding health and safety incidents or concerns, and that these had been effectively reflected upon and used to drive improvement.

Lessons were not always learnt and acted upon. For example, the ambulance service raised a safeguarding alert with the local authority on 9 June 2025 due to concerns about people not having access to medicines at night. When we visited on 30 June 2025, no action had been taken to mitigate this identified risk. Staff trained to administer medicines were not on duty at night which meant people were unable to access their medicines if required.

Systems and processes for recording incidents were not always completed. For example, a person had wounds on their arms and legs. These were not clearly documented on a body map for staff to know where they were and report any additional wounds.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There was evidence of delays in seeking medical attention when people’s health had deteriorated and poor escalation of risks to relevant health professionals.

We reviewed an accident form dated 26 June 2025, where a person had been found lying on the floor in their bedroom. The form stated, no injuries were sustained. However, on 30 June 2025 we saw wounds to the person’s left shin. One of the wounds was uncovered and weeping. This wound had not been escalated to health professionals. We raised our concerns with the management team, who proceeded to contact the community nursing team for support to manage these wounds.

Another person was known to be unable to report when they were in pain or distress. Their care plan did not include any information to help staff recognise when the person was in pain. This meant there was a risk pain experienced by this person would not be identified.

This did not demonstrate a service which managed and monitored people’s health conditions to ensure positive outcomes for people.

The provider did not always work well with people and healthcare partners 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.

The provider did not always share concerns quickly and appropriately. During our assessment, we found a person was not receiving time sensitive medicines appropriately with regards to their health condition. As a result, we had to raise a safeguarding alert on 4 July 2025. This did not demonstrate a service which responded to safety concerns in a timely manner.

People did confirm they felt safe with the staff that supported them and felt able to raise any concerns. People and their relatives commented, “Yes, they look after me well. I feel safe, they check on me regularly”, “I feel safe and looked after” and “Staff very friendly and polite, if we ask anything they tell us.”

Staff demonstrated an understanding of what might constitute abuse and knew how to report any concerns they might have. Staff received safeguarding training, to ensure they had up to date information about the protection of vulnerable people.

If needed, appropriate legal authorisations were requested to deprive a person of their liberty. Any conditions related to Deprivation of Liberty Safeguards (DoLS) authorisations were being met.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a lack of awareness of risks associated with people’s support needs. Staff did not always identify and manage risks proactively and effectively to keep people safe. Care and support was not always planned and organised with people, together with health and social care professionals, in ways that ensured continuity.

Risk assessments were contradictory and lacked detail. For example, a person’s falls risk was not well managed. Their falls risk assessment, reviewed on 23 June 2025, stated they were at 'high' risk of falls and their care plan stated they were at ‘medium' risk of falls.

Another person’s skin integrity care plan stated they were at low risk of developing pressure sores. Their care plan was overdue for review, and also stated the person was at low risk of developing pressure sores. The person’s needs had changed following a recent hospital admission where they were now bed bound. Hospital admissions and being cared for in bed are known risk factors for people developing pressure sores and should have been reflected in their risk assessment so staff knew how to keep them safe. In addition, the community nursing team were involved regards to a wound to this person’s ankle on 10 June 2025. These changes in the person’s needs were not reflected in their skin integrity care plan or risk assessment.

A further person’s critical information profile stated they were allergic to beta blockers, but this information was not reflected in their medicines care plan, which stated ‘no known allergies’.

These inconsistent recordings in relation to risk unnecessarily exposed people to risk of harm.

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

The provider did not have good oversight of all aspects of the premises. Health and safety checks were inadequate in identify and address safety issues related to the environment.

Fire safety management did not fully protect people or others within the building, placing them at risk of harm. A fire extinguisher which should have been serviced annually had not been serviced since 2017. Two evacuation chairs located on the 1st and 2nd floors showed no evidence of being serviced. A bedroom door did not fully close and there was expanding foam around the door frame. There were multiple fire doors which had damaged door frames, with either broken or missing locking catches, meaning these doors did not close properly. The staff room door was propped open by a chair contrary to fire safety procedures.

Out-of-date extinguishers may not function correctly during an emergency while damaged and propped open fire doors may allow fire to spread unchecked. This meant people were unnecessarily exposed to significant risk of harm.

We raised our concerns with the home manager who took action to address the risks found. We were provided with evidence of them communicating with external contractors specialising in fire safety regards to the out of date fire extinguisher, the evacuation chairs and the bedroom door with the expanding foam.

The décor of the premises looked tired with a general feel of wear, tear and a lack of investment. In addition, the provider’s environmental risk assessment had not been completed since 15 October 2024.

The home manager completed a walk around the building during the inspection and made a list of works that needed to be completed around the home. The provider asked the home manager to oversee the management of maintenance going forward. The home manager also spoke to the maintenance person regarding the lack of records of maintenance jobs completed so that in future they could monitor progress with works undertaken.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing numbers on each shift were based on the needs of each person. However, staff were not always effectively deployed, meaning some people were left with no social interaction for long periods of time.

On 30 June 2025, we observed the environment was chaotic, with calls bells ringing and people shouting out for help. One person’s call bell was ringing for over 10 minutes before staff responded. We checked the person, and they were found lying on a soaking wet mattress protector, their bedding was on a chair and a sheet was on the floor. We requested support for this person, which was given. On the next two days of our visits, the atmosphere was a lot calmer, with people’s needs being met in a timely manner.

Night staff did not have the skills to meet people’s care needs. No members of night staff had received training in how to support people with their medicines, and this meant people were unable to access their medicines when required during the night.

Day staff were trained and supported to be competent in their jobs. Staff received training, which enabled them to feel confident in meeting people’s specific needs and identify changes in people’s health.

Staff did receive supervision, so they could discuss their learning and development needs and any concerns they may have. However, these were sporadic in frequency.

There were safe and effective recruitment and selection processes in place.

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

Infection control practices were not robust. We observed a staff member on 30 June 2025 cleaning a bedroom and ensuite using the same mop and bucket without replacement or sanitisation between zones. This method contradicts the organisation’s Infection Prevention Control (IPC) policy, which mandates a colour-coded system for mop heads to prevent cross-contamination. The staff member stated this is their routine practice, even rinsing the mop in the shower if faecal matter is present. The staff member told us they do not use a formal cleaning log or record-keeping system. Instead, they verbally inform a carer of tasks completed. There were no recording system in place detailing when cleaning task were completed.

Several bedrooms were observed with poor cleanliness standards. Issues included food stuck to flooring, food debris and dust accumulation beneath beds, dirty tissues present, and pressure mats with dried fluids. The lower ground floor shower room had unclean walls, mould on the shower mat, mould on the walls, wood shelving damp and disintegrating and an unclean toilet pedestal. Chairs in communal lounges and individual bedrooms were observed to be visibly dirty, with noticeable stains, dried fluids, and food residue. The shower head in the lower ground floor shower room was found to be unclean. The top floor shower room had mould in and around the shower tray. Carpets throughout the communal hallways were observed to be dirty and stained, indicating a lack of regular maintenance and deep cleaning. The toilet on the first floor was observed to have visible signs of urine and other unidentified substances on the pedestal and surrounding wooden plinth. There were worn and dirty furnishings in people’s bedrooms. There was stained bed linen and not enough clean linen available to enable people bedding to be changed.

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.

Medicines management practices were not robust. Medicines management was not in line with the service's own medicines policy dated May 2025, and the National Institute for Health and Care Excellence (NICE) ‘Managing medicines in care homes’ guidelines March 2024.

On reviewing 3 people’s medicine administration charts (MAR), we found:

A staff member administering medicines was unable to explain the critical importance of administering Parkinson’s disease medication at prescribed times. There was discrepancy between a person’s MAR entries and actual administration times of their Parkinson’s disease medicines. For example, staff had recorded the medicine as given at 8:00am was actually given at 9:30am. Due to these concerns, we made a safeguarding referral to Devon County Council on 4 July 2025, which the home manager was made aware of at the time.

Medicines requiring administration at 8pm were being given early to people requiring it, to allow for staff to finish their shift at 8pm. The MAR charts showed medicines signed for at consistent times, but these did not reflect real administration patterns. Night staff did not administer medicines, despite people having scheduled doses after 8pm.

A person’s health needs significantly impacted on their ability to communicate when they were in pain. A staff member explained they assessed the person’s pain level through signs such as, facial expressions, clutching of the stomach or changes in gait. These observation techniques for pain levels were not documented in the person’s care plans for ‘health and wellbeing’, ‘medication’ nor ‘communication, cognition and mental capacity’. Resulting in the risk pain may go unrecognised or untreated, and different staff may interpret pain indicators inconsistently, leading to delays in intervention.

There were no ‘as required’ (PRN) protocols to guide staff. Resulting in the risk of inconsistent use of PRN medicines.

We observed the medicine trolley left unattended with the key left in the door in the communal lounge on 4 July 2025. This meant there was a risk of people accessing medicines not suitable for them.

The medicines audit completed on 23 June 2025 had not identified the issues we found with regards to medicines management.