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 inadequate. At this assessment the rating has remained 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.

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. They did not listen to concerns about safety and did not investigate or report safety events. While there was some evidence that lessons learned were shared with staff, this was not done consistently, and opportunities to continuously identify and embed good practice were limited.

For example, the provider recorded safety events such as accidents and incidents and generated actions to investigate them. Despite this, there was a lack of evidence these actions were consistently completed or followed up in a timely manner to demonstrate appropriate action had been taken to prevent recurrence.

We continued to identify a high number of falls and incidents involving people experiencing periods of distress. This indicated lessons were not consistently learned to improve practice.

Where errors were identified, appropriate actions were not always taken to address them. For example, concerns relating to medicines management had not been resolved.

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.

For example, we received feedback from a visiting professional stating staff were working hard to improve the service. However, due to a lack of consistent management in recent months, staff did not always have a full understanding of people’s needs, including some specific clinical concerns about their knowledge and approach. However, the management team told us they planned to improve oversight by employing unit managers for each unit. This will ensure day to day running of the units and provide more hands-on support to staff.

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 did not always share concerns quickly and appropriately.

For example, senior managers identified some incidents meeting the threshold for safeguarding had not been appropriately recorded or escalated by the home manager at the time. These incidents have now being submitted retrospectively. This meant some safeguarding concerns which may have required prompt action were not addressed in a timely way. The provider attributed this to an oversight by a previous manager. A new procedure has been implemented to ensure there is adequate oversight of incident reporting.

Deprivation of Liberty Safeguards (DoLS) were not appropriately monitored and managed to protect people’s legal rights. Processes in place failed to ensure some people’s DoLS authorisations were renewed in a timely way. As a result, some authorisations had expired and had not been reapplied for promptly, meaning restrictions on people’s liberty may not have remained lawful.

However, safeguarding policies were in place, and we saw examples of concerns being reported as required. Staff had received safeguarding training, and both staff and managers told us they understood the procedures and who to contact if concerns arose.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things which mattered to them. For example, we found for some people, who were at risk of pressure ulcers, were not always repositioned in line with their risk management plan, to reduce the risk of skin breakdown. While we found people were unharmed due to these delays, it significantly increased the risk of skin damage.

Although regular staff knew people well and understood their risks, agency and new staff relied on care records which often contained conflicting information about people’s needs. This increased the risk to people, as they did not always have access to accurate, up-to-date guidance on how to support individuals safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

For example, not all call bells were accessible, as some were not working. Some doors which should have been locked were left unlocked, posing a risk to people however, these issues were resolved promptly. Whilst maintenance staff worked to maintain the environment, some parts of the environment needed attention. For example, we found some people’s bedroom fire doors did not close properly despite documentation stating these had been checked and worked properly. Although people had fire risk assessments in place, this posed a risk to people in the event of a fire.

In addition, not all call bells were accessible, as some were not working. On the first day of our two-day site visit, several areas of the home were also not clean.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care which met people’s individual needs. We received mixed feedback about staffing levels. Some staff and relatives commented they felt on occasions there were insufficient staff to meet people’s needs. A relative told us, “My worry is there’s 1 senior staff and 2 carers on at night. Most residents here need 2 carers for most things, so what happens if they’re attending to someone like mum?”

People felt more staff were required at times, although they acknowledged they were happy to wait for care staff to come and support them.

Safe recruitment procedures were followed, to make sure suitable staff were employed.

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.

For example, although staff had received training in infection prevention and control (IPC), we observed standards of cleanliness were not consistently maintained. On our first on site visit we found some areas, including people’s bedrooms, communal toilets, and the communal lounge, required cleaning as they were visibly dirty. In addition, some mattresses and bedding were visibly unclean and had a noticeable malodour, indicating appropriate cleaning procedures had not been followed. These concerns were raised with staff, and they acted promptly to address them.

We found concerns relating to food storage practices. Some food items in the fridge were not clearly labelled with opening dates, and others had been left outside of refrigeration. For example, we found milk and some yogurts were left out of the fridge This practice increases the risk of contamination and does not align with safe food storage procedures.

However, these concerns were raised with staff, and they responded promptly to address them.

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 their care.

When people were prescribed topical preparations such as creams, information to support staff to know where to apply the creams was not always available, and records did not show creams were always applied as prescribed. There was a risk people’s skin might not be cared for properly.

We found one container of thickening powder, which was added to fluids to reduce the risk of choking, was not kept safely, and was accessible to people, placing them at risk of harm. The temperature of the medicine fridges was not monitored in line with the providers medicines policy, there was a risk the medicines were not stored at the correct temperature, which might affect their efficacy. Medicines awaiting destruction were not stored according to policy or national best practice guidelines.

Additionally, we found the manufacturer’s instructions were not always followed when administering medicines. We found medicines which should be given before any other medicines were given at the same time as another medicine and when a medicine required a specified time interval between doses, this was not always observed. This placed people at risk of experiencing side effects and there was a risk the medicines might not work properly.

Staff told us they had their competency assessed, and we saw records to support this. However, with the concerns found, we were not assured the assessments were effective in assessing staff competence.

The provider completed audits regularly, the audits showed areas for improvement. However, the audits had not identified all the concerns identified.