Albert Road

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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

We identified recurring concerns over extended periods, particularly in relation to resident-to-resident conflict, community safety risks and dysphagia management. Whilst actions had been taken, including support plan reviews, safeguarding involvement, behavioural monitoring and multidisciplinary engagement, there was less evidence demonstrating that leaders had consistently evaluated the effectiveness of those interventions or assured themselves that the likelihood, frequency or impact of similar incidents had reduced over time.

We also identified inconsistencies in how learning arising from significant incidents had been translated into day-to-day practice. Following a significant incident, the provider introduced additional measures relating to dysphagia management, recording requirements and mealtime oversight. However, we identified gaps in records and inconsistencies in how these measures were followed. This reduced assurance that learning had been fully embedded and sustained across the workforce.

However, records demonstrated that incidents were investigated, debriefs were undertaken and learning was shared through team meetings, governance processes and organisational communication systems. Staff understood how to report concerns, describe escalation processes and access information about the people they supported. Leaders demonstrated openness when reviewing incidents and identifying opportunities to improve safety, and there was evidence that action was taken in response to concerns when they were identified.
 

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.

Care records, incident reporting systems, handovers and established escalation arrangements enabled staff and managers to communicate important information about people's needs, risks, and support requirements. Professional guidance informed care planning and risk management, helping to help ensure support remained aligned to people's changing needs.

People benefited from coordinated support involving a range of healthcare professionals and agencies, including GPs, Speech and Language Therapists, physiotherapists, mental health services, safeguarding teams, commissioners and local authorities. Referrals were made when concerns were identified and professional guidance was reflected within care plans and support arrangements. This helped support continuity of care and promoted a coordinated approach to meeting people's needs.

Handover systems helped staff remain informed about appointments, healthcare involvement, incidents and follow-up actions. Staff demonstrated a good understanding of the people they supported, and records showed that care plans and risk assessments were reviewed and updated when people's needs changed, supporting continuity and consistency of care.
 

The provider did not always optimise opportunities to improve people’s lives or to protect their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We identified behavioural incidents, compatibility concerns between people using the service and safeguarding referrals associated with changes in presentation and support needs. Safeguarding records and reviews demonstrated that actions were often recorded following incidents; however, the rationale for those actions and the arrangements for evaluating their effectiveness were not always clearly evidenced. This was particularly relevant where repeated safeguarding concerns involving the same individuals continued over time despite reviews, support plan updates and safeguarding involvement.

However, the provider had established systems to identify, record, investigate and respond to safeguarding concerns. Safeguarding matters were appropriately referred to partner agencies where required, and records demonstrated involvement from safeguarding teams, healthcare professionals, social workers and other external organisations. Leaders maintained oversight of safeguarding activity through governance processes and monitoring systems, providing assurance that concerns were recognised, investigated and progressed appropriately.

The provider also had arrangements in place to support the Mental Capacity Act and Deprivation of Liberty Safeguards. Records demonstrated oversight of DoLS applications, authorisations and renewal dates, and applications had been submitted where required. However, monitoring arrangements were less robust in relation to Relevant Person's Representatives, reviews of mental capacity assessments and best-interest decision-making, with oversight relying heavily on manual management monitoring.
 

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.

Risk assessments were person-centred and reflected individual needs, preferences and known risks. People were supported to maintain independence, access their local communities and participate in activities important to them, whilst appropriate measures were taken to reduce the likelihood of harm. Staff demonstrated a good understanding of individual risks and the support required to manage them safely.

Positive Behaviour Support approaches, communication strategies and other personalised risk-management interventions were present within care planning. The provider also demonstrated awareness of the Mental Capacity Act and the importance of supporting people to make decisions wherever possible, with restrictions linked to identified risks and legal frameworks where required.

However, opportunities remained to strengthen how the effectiveness of risk-management interventions was evaluated and evidenced over time. Whilst risks were reviewed and support plans updated, records did not always clearly demonstrate the impact of interventions or how their effectiveness had been assessed following implementation.
 

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 service had effective arrangements in place to manage environmental risks associated with people's needs. Appropriate plans were in place to support people in emergencies, and safety systems, equipment and environmental checks were regularly reviewed and maintained. Statutory requirements relating to areas such as fire safety, water safety and equipment servicing were up to date.

People benefited from an environment that promoted independence whilst helping to keep them safe. The premises were clean, accessible and free from significant environmental hazards.
 

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.

The provider had systems in place to recruit staff safely and ensure people were supported by a suitably skilled and competent workforce. Recruitment records demonstrated that appropriate pre-employment checks had been completed before staff started work.

Staff received relevant training and demonstrated a good understanding of people's individual needs, risks and support requirements. Training compliance was generally good and staff were able to explain how they supported people safely and responded appropriately when concerns arose.

The provider monitored training compliance and competency through organisational systems and had introduced additional learning following incidents and emerging risks. This provided assurance that staff had the skills, knowledge and support required to deliver safe and effective care.
 

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.

Staff understood their responsibilities for maintaining cleanliness, hygiene and safe working practices. Personal protective equipment was available and used appropriately, and staff were able to explain the actions they would take if infection concerns arose.

Systems were in place to support infection prevention, including environmental monitoring, routine checks and guidance for staff. Care planning reflected people's individual health needs and identified where specific infection-control measures were required. Staff demonstrated a good understanding of people's health needs and the importance of reducing the risk of infection and cross-contamination.
 

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 managed through structured systems designed to promote safe and effective administration. Clear arrangements were in place for the ordering, receipt, storage, administration and disposal of medicines, supported by regular stock checks, temperature monitoring and staff competency assessments. Staff responsible for medicines administration had received appropriate training and records demonstrated that medication management formed part of the provider's wider governance and oversight arrangements.

People received support with their medicines in a way that reflected their individual needs and circumstances. Care planning contained detailed guidance for routine and PRN medicines and recognised factors such as cognitive impairment, communication needs and dysphagia risks. Where required, staff followed personalised protocols to support safe administration and ensure medicines were provided in a manner people could understand and manage.

Clear escalation procedures were in place for medication errors, concerns or adverse events, and staff understood the actions required should issues arise. Overall, people were supported by systems and processes that promoted the safe, person-centred and effective management of medicines.