Amphion View 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 changed to 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 legal regulation in relation to people’s safe care and treatment and safeguarding people from abuse.

This service scored 53 (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.

There were systems and processes in place to learn lessons, including when incidents and accidents occurred. The registered manager confirmed they monitored records of accidents and incidents so any trends or patterns could be identified and acted upon, and action plans were put in place to reduce the risk of them happening again.

The management team understood their duty of candour, to be open and honest when things went wrong. For example, when incidents had occurred in the home, these were immediately communicated to relatives and reported to professionals appropriately.

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.

Staff worked with a range of other health and social care professionals such as speech and language therapists, dieticians, social workers and local authority and health care commissioners. Working in partnership with these other professionals helped to achieve positive outcomes for people.

Although we were assured the provider concentrated 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 systems did not always ensure any restrictions were legally justified, proportionate, necessary, or used only as a last resort.

Relatives of people supported said people's safety was promoted. Their comments included, “I am very happy with my [relatives] care, no sign of abuse, they are kept very safe,” Another relative said, “Yes [relative], is kept absolutely safe, the staff are nice, keep me informed if [relative] is unwell or had a fall.” While people expressed general satisfaction with their care, our assessment found elements of care did not meet the expected standards.

Staff were trained in how to recognise and respond to abuse and understood their responsibility to report any concerns to the management team. This meant staff understood their responsibilities to protect people from harm.

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.

During the inspection, we identified several people living in the home who lacked the capacity to consent to their care and support. At times, their bedroom doors were locked from the outside to restrict external access. However, they could be unlocked from the inside This was for peoples own safety. While this may have been intended to reduce risk, we found mental capacity assessments and best interest decisions had not consistently been completed. In cases where best interest decisions were recorded, it was unclear whether the least restrictive options had been actively considered. Care plans lacked sufficient detail about the nature of these restrictions, and the checks staff were expected to carry out to ensure people’s safety. As a result, we could not be assured this practice was legally justified, proportionate, necessary, or used only as a last resort. Following the inspection the provider undertook mental capacity assessments and best interest decision making processes to ensure their practices met with legal and regulatory requirements.

The provider had systems in place to make DoLS applications and to renew applications in a timely way to ensure people's rights were maintained. We saw the registered manager maintained a tracker to document when applications had been submitted to a local authority to authorise restrictions in place to ensure individuals received the care they needed. At the time of inspection, the provider had made 14 applications to local authorities for DoLS authorisations for people living in the home to ensure they were deprived of their liberty legally. Of these, 13 had their deprivation of liberty authorised by the local authority and the service was waiting for the local authority to decide on the remaining applications.

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

Relatives told us they were contacted by staff and management following incidents occurring or new risks emerging involving their loved ones. They told us they received information about changes to people’s support needs. While people expressed general satisfaction with their care, our assessment found elements of care did not meet the expected standards.

People’s risk assessments and care plans lacked adequate details of people’s individual needs and the care they required. For example, where people’s bedroom doors were locked for their own safety, care plans did not specify how often checks needed to be made on the person. In addition, people’s personal evacuation plans (PEEP) did not identify who had locked doors and the numbers of staff required for a safe evacuation.

Some people living at Amphion View had complex dementia care needs and could demonstrate heightened levels of anxiety or agitation. Whilst people had behaviour support plans, they were mostly generic and did not contain sufficient detail about people’s individual triggers or diversion techniques for staff to use. Individualised positive behaviour support uses detailed and personalised information to understand the reasons behind people’s responses, rather than just reacting to them. There was a risk staff would not be able to support people in a safe way and promote positive outcomes during incidents of distress.

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. Several areas of the home appeared tired and required refurbishment and redecoration. Window restrictors were not fitted to all windows. This increased the risk to people who could fall out of windows. One bedroom window on the first floor was cracked, and the window restrictors were not working effectively. Fire safety was not consistently well managed. Information staff and the emergency services needed to keep people safe in the event of an emergency was not up to date. Personal emergency and evacuation plans (PEEP) were in place however the PEEP folder did not contain assessments for 4 people who were at the service and did not identify when people had their bedroom doors locked. We discussed this with the registered manager who said they would take immediate action to review peoples plans.

We carried out a tour of the home and found some environmental factors which posed a risk to people. For example, one person’s bedroom furniture was not attached to the wall and therefore there was a risk of it falling onto someone. The provider and registered manager responded immediately during the inspection to address these issues.

There were sufficient staff available, with the right skills and experience to keep people safe and provide high quality care. People and relatives told us there were enough staff to keep them safe. Staff raised no concerns about staffing levels. We saw staff responded to people quickly and assisted them in line with their needs.

Records confirmed a range of checks including application, interview, and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. However, we found gaps in recruitment records. The registered manager was responsive to the concerns raised and immediate action was taken for the records identified and a review of other records was to be completed.

Staff felt supported in their roles and were able to gain advice and guidance when required. Staff told us they completed a range of training that gave them the skills and knowledge required to meet people’s needs and keep them safe. However, one staff member said, “We support some very complex people, and it would be helpful to have more training on how to deal with people who are challenging.” We shared this information with the registered manager.

The service did not always assess or manage the risk of infection. While the people we spoke to said they were happy with the environment, our assessment found elements of care did not meet the expected standards. Not all areas within the home were well maintained to facilitate good infection and control procedures.

The provider was not promoting safety through the layout and hygiene practices of the premises. There were cracks in the plaster on walls, stains and marks on furnishings and flooring, and equipment that needed cleaning or replacing. We found there were strong malodours in areas of the home. Paintwork was chipped, radiator covers damaged and some of the walls and door frames were damaged and needed refilling and repainting.

Some areas of the home were in a poor state of repair. This inhibited good cleaning practices and increased the risk of bacteria harbouring and infection spreading. Staff completed regular cleaning with appropriate products. However, their efforts were compromised by the poor state of repair of the home which meant some touch points were difficult to clean effectively.

There were several bathrooms in use. Across the bathrooms and toilets, we found equipment needed to be cleaned or repaired. For example, we found a dirty shower chair, soiled toilet seats and leaking toilets. Furniture was visibly stained and there were malodours in the home.

This was discussed with the registered provider who said there was a service improvement plan in place, and they would take action to ensure the service was 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.

People received their medicines as prescribed. Staff had been trained in administering medicines and their competence regularly checked. People who received 'as required' medicines, where appropriate had protocols in place to guide staff to administer medicines effectively and in line with people's individual needs.