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 inadequate. At this assessment the rating has changed to good.This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Staff and leaders demonstrated a positive learning culture. Incident and accident logs were maintained and there was clear evidence that lessons were learned from events. Staff spoke about how learning was shared across the team in team meetings, and handovers at the start of their shift. Records showed that there was now a robust pathway to cascade safety events to the teams to improve good practice.

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 moving in and out of the service were well coordinated, supported by clear and recorded communication between staff and external professional. People told us they felt supported during these changes. One staff member told us, “First we get information from other professionals [The registered manager] goes to assess them, their likes and dislikes and we talk to family, it's in the plans, you find a lot about them by talking to them too”.

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 and relatives told us they felt safe and they knew who to approach if they had a concern.

Staff had completed relevant training and understood their responsibilities relating to the Mental Capacity Act 2005 (MCA).

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 provider was able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications or/and urgent authorisations in a timely manner.

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 encouraged to make informed choices while staying safe. Risk assessments were in place and reflected personal preferences. Relative comments included,"They have [Name] on a good diet that has helped with weight management’ and “We’ve been involved with the care plan”.Staff told us they were informed of people’s risk assessments and were kept up to date with changes. One staff member told us, “We are kept up to date with everything, we are informed, we have care plans on the [Electronic device] there are written ones as well. We can look at them at any time”.

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 premises were clean, well maintained and free from hazards. A refurbishment plan was in place, and we observed ongoing maintenance throughout our visit. People told us they were comfortable in their surroundings and felt safe. Staff spoke positively about the improvements the provider had made to the décor which made the environment homely and welcoming.Fire drills were carried out monthly and recorded, lessons learned were documented.

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.

Recruitment processes were safe and staff were deployed appropriately. Staff training and development was in place. There were mixed views about staffing levels, most people told us there were enough staff. Comments from staff included, "We manage with what we have and we manage quite well” and “they do it on a ratio, we manage”.Staff training and supervision was completed and recorded with a robust system in place to ensure compliance. Comments from staff included, “Supervisions are monthly, [The registered manager] does them, we can share ideas and concerns, and it is written down”.

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.Personal protective equipment [PPE] was available and used correctly, and the home was clean throughout. Staff had completed relevant training and followed hygiene protocols. Cleaning audits were completed and any issues escalated appropriately.One staff member told us, “We never run out of PPE”.

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.

Medicines were stored securely, and drug trolleys were secured to walls and locked when not in use. The use of thickener for people at risk of choking was appropriately stored, and it was not accessible to residents. Residents’ folders were well organised, and medication administration records (MARs) were complete, and records included documentation of thickener use.Temperature checks were completed twice daily to ensure medicines were stored within the required temperature ranges.People prescribed ‘as and when required’ (PRN) medicines had protocols in place; however, some protocols required further detail to ensure they were fully person-centred.Patch rotation charts were in place to support staff to apply patches to different areas of the body to reduce the risk of skin irritation and support effectiveness.

Body maps were in place for people prescribed creams and emollients, which guided staff on the correct areas of application. Fire risk assessments were also completed for people prescribed paraffin based emollients.Staff told us about the improvements that had been made relating to medicine management since our last assessment, one staff member said, “There has been a lot of different things put in place”.