Arncliffe Court 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 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 inadequate. This meant people were not safe and were at risk of avoidable harm.The provider was in breach of legal regulation in relation to safe care and treatment, medicine management, consent and staffing.

This service scored 25 (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. The provider’s systems for investigating, reporting, and learning from safety incidents were not robust, and appropriate actions were not always taken in response to incidents or accidents. For example, we observed an incident involving a person who was experiencing emotional distress which they expressed physically towards others. However, incident records were not thoroughly reviewed to identify patterns or trends, and little action was taken to reduce the risk of similar incidents occurring. The provider had failed to provide training to staff to guide them on how to effectively support people during periods of emotional distress and reduce the risk of harm to themselves or others. We identified concerns at our previous inspections regarding medicines management, risk assessments, and cleanliness. We found these concerns had not been effectively addressed. The provider had not learned lessons and had not taken the necessary actions to improve the quality and safety of the service.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. Preadmission assessments were not always completed thoroughly before people moved into the home. This meant staff did not have a full understanding of peoples’ healthcare needs, and associated risks. For 1 person, no pre-admission assessment had been completed, and this placed the person at risk of not receiving care which met their needs or kept them safe from avoidable harm. Another person who had transferred from a different care home still had information from their previous service in their care plan. This information did not reflect their current care needs, such as their ability to mobilise independently which meant staff did not have current up to date records to support the person effectively. We observed the person struggling to mobilise and supported with the wrong equipment as recorded in their care plan. We spoke with management who assured us they would speak with staff and update the care records.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve it. 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. While staff were aware of the signs of abuse, several had not completed safeguarding training in line with the provider’s own policies. Although the registered manager had reported some concerns, we found some people’s care needed to be safeguarded due to the lack of appropriate support provided to meet their needs. This was not picked up by the registered manager which meant people were at risk of harm.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People with known medical conditions did not always have assessments tailored to their specific needs. For example, a person living with epilepsy did not have clear guidance in place for staff on how to respond if they became unwell due to their condition. Risks related to mobility, wound care, diet, and nutrition were not consistently assessed to inform staff on how to provide safe and appropriate support. This placed people at risk of harm due to ineffective care. Risk assessments were in place; however, they contained conflicting information and did not provide staff with clear guidance on how to identify or manage risks effectively. For example, where people experienced emotional distress, this had not been fully assessed. While some information was available about possible triggers for the distress, staff did not demonstrate a clear understanding of how to respond appropriately to people to minimise their distress and ensure their wellbeing.

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. The provider did not ensure there were enough competent staff or sufficient guidance was in place to manage a safe and efficient emergency evacuation in the event of a fire. This placed people at risk of avoidable harm. The provider did not complete safety checks on people’s specialist pressure relieving equipment put in place to reduce the risk of skin injury to ensure they were functioning. We observed equipment such as air flow mattress monitors with alarms signalling, they needed attention however, this was not picked up by staff or the providers monitoring systems. We were not assured the equipment was operating effectively and this placed people’s skin integrity at risk.

The provider did not make sure there were enough qualified, skilled and experienced staff deployed to safely meet people’s needs. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care which met people’s individual needs. Our observations found staffing levels were not always adequate to ensure people received consistently safe, good quality care. We observed extended periods where only two staff members were on duty, despite several people requiring the support of two staff for personal care and moving and handling. As a result, there were times when no staff were available to supervise communal areas or respond promptly if someone required immediate assistance. On one occasion, when a person requested support with continence, a staff member explained they could not assist immediately as they were waiting for the scheduled toileting round and there were staffing limitations on the unit. Although staff had received mandatory training, they had not received training to meet people’s individual needs such as diabetes and stoma care. We received mixed feedback from staff about the frequency of supervisions. However, staff told us they generally felt supported by management.

The provider did not always assess or manage the risk of infection. People were not always protected from the risk of infection because premises and equipment were not kept clean and hygienic. Although staff had received training in Infection Prevention and Control (IPC), we found some people’s bedrooms, communal toilets and the communal lounge needed cleaning. There was no dedicated place for keeping personal protective equipment (PPE) for staff to use when supporting people with personal care or handling bodily fluids. We found a container which stored PPE with faecal matter and some PPE were stored in people’s bedrooms and in dining areas. This compromised infection prevention and control measures, increasing the risk of cross-contamination. The manager informed us they had cleaners every day, however, there was little evidence to suggest some units had been cleaned. A staff member told us, “We have been asked to do some housekeeping duties alongside our caring responsibilities, this is too much as we haven’t got the time to do so which means some areas will go unclean.” A person told us, “I hate sharing the toilets, they are always dirty. When I ask staff to clean them, they say we can’t keep an eye on them all the time.”

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. We found medicines records did not always give assurance medicines were administered as prescribed. We found for 1 person did not receive one of their medicines for 18 days and this placed them at risk of harm. The electronic medication record (EMAR) recorded the time medicines were administered. We found for 2 people, the prescribed interval for some medicines had not been observed, or medication prescribed to be given at a specific time had not been administered as prescribed. Staff did not always record when thickened fluids were being given to people who were at risk of choking and aspiration. From reviewing the records, we could not be sure prescribed thickening agents were being managed safely, and this placed people at risk of choking. Peoples care plans and medicines records did not always contain the information needed for staff to manage people’s health conditions. For example, for people prescribed their medicines to be given covertly (hidden in food and drink), there was not always enough information to ensure staff could give these medicines safely. For people prescribed medicines to be given ‘when required’, protocols did not always contain person centred information to ensure staff could give these when appropriate. For people prescribed medicines patches there was not always a record of where this was applied on the body. This meant we had limited assurance the application of the patch had been rotated in line with manufacturer’s instructions. Storage of medicines was not always managed appropriately. We found temperature monitoring of areas used to store medicines was not always recorded in line with the providers policy. We found medicines were not always stored in line with the manufacturer’s instructions, and for medicines which have a shortened expiry once opened, we found staff did not always record the date of opening. This put people at risk of receiving a medicine which had expired. Not all staff had their competency assessed for tasks related to medicines administration in line with best practice guidance.