Allenbrook Home (Halesowen)Ltd

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.

Good: This meant people were safe and protected from avoidable harm.
 

This service scored 63 (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. Management listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed improvements. Accident and incidents within the home were investigated and actions were evidenced. Staff we spoke with told us they were involved in debriefs after an incident, which included learning for the future. Staff told us they felt confident in speaking up and in putting forward ideas for the service to improve. One staff member told us, ‘[Registered manager] does a review of all incidents and accidents and calls a meeting with those involved for a serious case review and we look at lessons learned and future actions.’

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider raised during this assessment they had received conflicting information from partners and this had left them unsure about what records and detail need to be in place for people. For example, people who had equipment in place to mitigate pressure areas, such as an air flow mattress, did not have recorded what level the air flow should be set to. This is important as the air flow needs to match the person’s weight. We raised this during the inspection and the registered manager informed us they had been informed not to include this by another partner. Whilst no impact to people was evidenced, there was a potential risk of harm due to the service receiving conflicting information. Where people had specific health diagnoses care plans had detailed sections of how staff care, monitor and maintain the conditions safely. For example, where a person had a diagnosis of diabetes, they had a specific plan in place, which provided guidance to staff on the different sugar levels the person may display and what to do in the instances of a person becoming unwell. The provider had a detailed process for assessing people who moved into the service. This included assessing their personal needs. We found evidence where people required mobility equipment, guidance from health professionals had been gained and this had informed care plans.

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 protecting people’s rights to live free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. During the assessment we identified 5 incidents that were reportable to CQC. We raised this with the provider who informed us they couldn’t find the appropriate category to submit the notification. During the inspection the provider submitted the notifications. We saw evidence that even though CQC had not been informed, the provider had reported to safeguarding, completed an investigation and followed their policy and procedure. Staff were trained in safeguarding. One staff member told us, ‘I would report a safeguarding concern straight away to the manager, if I felt not dealt with correctly, I would speak to the provider.’ Staff we spoke with told us they felt confident in speaking up. Staff were aware of protocols and external partners they could contact if they were not happy with the response from the management or provider.

The provider worked with people to understand and manage risks. The provider did not always update people’s risk assessments to identify their updated care needs. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans for people did not always consistently match details recorded in risk assessments. For example, one person was assessed to use a standing frame for their mobility needs, and where they were not able to use the standing aid they could be hoisted. The risk assessment still showed the person was hoisted by two members of staff. During the assessment the registered manager took action to review and amend the care plan and risk assessments to ensure they were consistent and factual. A further example was where other residents were identified to use standing frames, care plans detailed 2 staff members would need to support with this moving and handling task. However, on observation, only 1 staff member was supporting. We raised this with the registered manager who evidenced this had been assessed and cleared by the Occupational Therapist. It was agreed the detail in care plans had not been updated. The service had good oversight of people’s monitoring charts. For example, where people required their fluids to be monitored, there was evidence this was included and documented in handovers, which also highlighted any concerns staff had of people not meeting their daily fluid intake targets.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. The home was clean and nicely decorated. People had the option to sit in the conservatory for quiet time and to eat their dinner. The lounge had plenty of seating. We did raise during the visit that the seating was not positioned in an inclusive way for people to socialise. The registered manager told us this was not how the seating was usually positioned, however, during the day with visitors and activities the seating ends up been moved around. The registered manager, deputy manager and director had regular presence in the home and completed walk arounds. The service had an on-site maintenance staff member who we found was responsive to any environmental concerns and completed regular health and safety checks. Several people told us how good the maintenance service was. Fire checks were completed regularly, which included fire equipment checks ensuring fire alarms were working and keeping people safe in the event of a fire.

The provider had a proactive and positive culture of safety, based on openness and honesty. Management listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed improvements. Accident and incidents within the home were investigated and actions were evidenced. Staff we spoke with told us they were involved in debriefs after an incident, which included learning for the future. Staff told us they felt confident in speaking up and in putting forward ideas for the service to improve. One staff member told us, ‘[Registered manager] does a review of all incidents and accidents and calls a meeting with those involved for a serious case review and we look at lessons learned and future actions.’

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. There was enough personal protective equipment (PPE) situated around the home. Staff we spoke with all told us there was enough PPE available. The home had designated cleaning staff. We observed staff cleaned thoroughly and consistently throughout the day. Cleaners followed cleaning schedules, and these were signed off daily once completed. The home was nicely decorated and well kept. One person told us, ‘Staff wear gloves and aprons and when finished screw them up so they don’t take my germs to someone else.’ A relative also told us, ‘Staff always wear gloves and aprons when I see them doing personal care.’

The provider mostly made sure medicines and treatments were safe and met people’s needs, capacities and preferences. During our visit we observed a nurse administering medication to a person who was laying sideways. The nurse proceeded to give the person medication and a drink whilst in this position. The person was at risk of and prone to developing pneumonia. We raised this with the registered manager. The registered manager assured us they would be speaking to the nurse and taking action where appropriate. Pain scale records were not effective. Pain scales did not detail people’s individual pain needs. The service completed weekly medication stock checks and audits were in place daily. Staff who administered medication had received appropriate training and competency checks. One relative told us, ‘I feel staff are well trained and give medication safely.’