Allendale Residential Home Limited

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 75 (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.

People told us they felt confident raising concerns with care staff or managers and said they would be listened to if anything worried them.

Staff demonstrated a clear understanding of how to identify, report, and escalate concerns or incidents, both internally and externally when required. Staff told us they felt confident to raise concerns and said these would be acted upon. The registered manager ensured learning from safety events was shared and acted upon. Management communicated information effectively through handovers, team meetings, face-to-face discussions, and online messaging to support staff learning and service improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or checked. They made sure there was continuity of care, including when people moved between different services.

The registered manager carried out pre-admission assessments to ensure the service could meet people’s needs. Where possible, they invited people to visit the home as part of this process. This gave people and their families the opportunity to view the service and allowed staff to assess the person’s suitability in the appropriate environment. Managers, staff, and relevant professionals worked with people and their families to support a smooth transition into the service.

One family member told us, “We knew as soon as we walked in that it felt right. We didn’t even bother seeing the other 2 (care homes) we had been given to consider.”

The registered manager maintained appropriate records and shared relevant information to support planned moves when people’s needs changed, and they required transition out of the service.

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 consistently told us they felt safe at the service. All the people we spoke with confirmed they felt protected and supported by staff. One person told us, “[Staff] treat me well, they're good people… I’ve no worries…oh I feel safe enough.”

The provider had effective safeguarding procedures in place to protect people from abuse. Staff received appropriate safeguarding training and demonstrated a clear understanding of their responsibilities. They told us they felt confident to raise concerns and were assured these would be taken seriously and addressed promptly.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the registered manager showed a clear understanding of their responsibilities under the MCA. Staff supported people in ways that upheld their rights and showed a good understanding of the Act’s principles. Staff understood the importance of gaining consent and told us they would inform managers of any changes in a person’s capacity.

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.

The provider maintained up-to-date care plans and risk assessments to guide safe care. Managers reviewed these monthly, or sooner where required. They included clear and detailed information to support staff in delivering care safely. For example, risk assessments set out how people should be supported with food and drink to reduce the risk of choking. We observed staff followed this guidance in practice.

Staff demonstrated a clear understanding of the need to balance people’s independence, choice, and rights with the delivery of safe care. Documentation, including risk assessments and best interest decisions, clearly outlined how support should be provided and the rationale for any restrictions.

Families told us the service communicated effectively with them. They described very good information sharing by the home, which helped them feel involved, included, and regularly updated about their relative’s health and wellbeing.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider maintained safe premises through regular environmental risk assessments and audits. These identified potential hazards within the home that could affect people using the service and staff delivering care. Managers reviewed the findings and took action to reduce identified risks and promote safety for everyone. The provider maintained the required safety certificates.

The provider employed a maintenance person to ensure any issues were addressed promptly. At the time of the assessment, the home had a planned programme of redecoration in place, including the maintenance of doors and woodwork.

Radiators in bedrooms had protective covers in place. Managers confirmed they planned to install radiator covers in other accessible areas to further reduce risks.

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.

The provider followed safe recruitment practices to ensure staff were suitable to work with people using the service. Managers completed pre-employment checks for all staff before they started work. These included Disclosure and Barring Service (DBS) checks.

The provider supported staff to develop the skills required for their roles. New staff completed an induction programme, which included online and face-to-face training, as well as shadowing experienced staff. Ongoing supervision, competency assessments, and spot checks supported continuous learning and helped ensure staff delivered safe and effective care.

Staff told us there were enough staff on each shift to meet people’s needs. A relative confirmed this and told us, “There are enough staff at all times, and believe me, I have been there at all hours of the day and night.”

The registered manager prioritised supervision for new and night staff. They had a plan in place to ensure all other staff received regular supervision.

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.

The provider maintained effective infection prevention and control (IPC) practices to reduce the risk of infection. Staff received training in IPC and safe food handling, where required. Personal protective equipment (PPE) was available, and we observed staff used this appropriately.

The provider ensured the environment was clean and well maintained. Cleaning schedules and regular audits monitored cleanliness and hygiene standards. Dedicated cleaning staff supported this, and during the assessment we found the environment was clean and free from odours.

Relatives confirmed the home was consistently clean. One relative told us, “They (care home) have always been meticulous about cleanliness, and the place is very well maintained.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider managed medicines safely. Staff stored, administered, and recorded medicines in line with best practice. Medicine records were clearly organised, colour coded, and easy to understand. Records for PRN (as required) medicines (such as paracetamol) were maintained separately and included the reasons for administration and the outcomes achieved. Body maps guided staff on the correct application of creams and the rotation of medicines, such as pain patches, to ensure safe and consistent practice.

The provider implemented effective systems to monitor medicines management. Managers carried out regular audits to ensure stock levels were accurate and that medicines were administered and recorded correctly. Staff received appropriate training, and managers completed regular competency checks to confirm safe practice.

The provider made policies and guidance readily available to staff, including medicines information sheets. Where medicines were not directly managed by the home, such as insulin and oxygen, the provider maintained appropriate checks and assurances to ensure these were managed safely.

Families told us medicines were managed well. One relative highlighted the importance of their family member’s medicines and told us, “Medication is closely controlled” by staff at the home.