Aston Manor EMI 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 changed to Inadequate.This meant people were not safe and were at risk of avoidable harm.The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 38 (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. Where incident and accidents had been logged, we could not see a process whereby lessons were learned to continually identify and embed good practice. We reviewed the provider’s complaints process. One complaint had been logged since October 2023; the investigation attached to the complaint was not robust nor did it have lessons learned or evidence of discussions with staff involved in the complaint. Staff told us they could raise concerns around safety if required to do so, however, we were concerned the processes in place were not sufficiently robust to ensure concerns would be dealt with appropriately.

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. The last person who moved to Aston Manor was admitted from hospital. The provider had not carried out a pre-admission assessment to ensure the service could meet their needs ahead of offering a placement. The pre-admission paperwork was completed on the day of their admission to the home. The registered manager told us that they did not have capacity to carry out a pre-admission assessment. This meant the registered manager and provider had not ensured they could appropriately meet the person’s needs prior to them moving into the home. This put them at risk of unsafe care and treatment.

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 had a safeguarding policy in place, and we found safeguarding incidents had been logged. The provider had not explored or completed lessons learnt around incidents and allegations to identify themes and patterns and prevent recurrence. The provider did not always share concerns appropriately with staff within team meetings to support lessons learnt.

The provider did not work well with people to understand and manage risks. The provider had not ensured that care and treatment was provided in a safe way. They did not ensure all risks to people were consistently assessed, recorded and managed. We found effective systems were not always in place to assess, monitor and mitigate risks to people and keep them safe. We identified some people’s needs were not met in respect of management of skin integrity, mobility and nutrition and hydration. This put people at risk of being harmed and their health and wellbeing deteriorating. People were not involved in assessing and monitoring their care plans. Out of 7 relatives we spoke with no one could recall any involvement or discussions regarding a care plan.

The provider did not 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. During our assessment inspectors observed the environment was not maintained to a high standard. The décor was worn and tired, the gardens were unkempt. Inspectors found a bath hoist did not have a lap belt; this placed people at risk of sliding off the bath hoist while being supported. Inspectors found a bottle of cleaning solution and other solutions such as glue left in unlocked cupboards in the lounge and activity room. Given the needs of people living at the service there was a risk these products could be accessed by people and cause them harm. Fire safety was not always well managed at the home. Fire extinguishers were stored in a linen cupboard and were not easily accessible if needed. We found people living at the service did not always have an accurate personal emergency evacuation plan (PEEP) in line with their needs. Fire drills were not completed regularly; the last one had been 6 months before our assessment. Fire extinguishers and emergency lighting safety checks were overdue. The registered manager rectified some issues identified during our assessment. The fire extinguishers were put back to their correct location and the safety checks on the fire extinguishers and emergency lightening were completed.

We found there were enough staff to support people. The provider did not always make sure staff received effective support, supervision and development. Leaders did not work together well to provide safe care that met people’s individual needs. The provider’s training matrix identified some staff were out of date with mandatory training deemed mandatory. Staff were not always recruited safely. We found some staff members reference checks were not always verified and employment history gaps not always explained. Some staff told us they had supervision with the registered manager every 6-12 months. Inspectors saw records of supervisions in staff files, but these were blanket supervisions giving staff information, they were not personalised or individual.

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. We observed domestic staff cleaning throughout the day. Staff had access to appropriate personal protective equipment (PPE) which they used effectively. However, inspectors found on more than one site visit, that some hand wash and hand sanitizer dispensers were empty. Relatives we spoke with told us they were satisfied with the environment. Comments included, “I am satisfied with the environment” and “I am more concerned that [person] is well cared for and safe”. Infection, prevention and control (IPC) audits and records were not always fully completed with gaps in audits.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not managed safely. We found prescribed fluid thickeners were not handled safely. For example, we saw a person’s fluid thickener was stored on a tea trolley. It was accessible to other people and had a potential to cause them harm. The consistency required to aid people’s safe swallowing was not recorded on their medication administration record (MAR) and staff lacked guidance at the point of dispensing to ensure people received thickener as prescribed for their needs. The provider could not demonstrate people’s medication was being given as prescribed. Staff were not recording the time medicines were given which and could not ensure safe and appropriate time intervals between doses. There was no evidence that topical medicines were managed safely as appropriate documentation was not always in place. Person-centred guidance to support the use of ‘when required’ (PRN) medicines was not consistently in place, and outcomes following administration were not always assessed or recorded to ensure the efficacy of medicines. For example, 1 person who lacked capacity and had difficulty communicating their needs did not have this reflected in their PRN protocol. The protocols were not stored with the MAR charts, making them less accessible to staff during medicine administration. There were no tools available at the service to support the assessment of pain for people unable to this communicate verbally. There was a risk people would not receive appropriate treatment if they were in pain. Best interest decisions were recorded for people who received their medicines administered covertly (disguised in food or drink). However, instructions for how to administer these medicines safely was not always in place.