44 Albion 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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to person-centred care.

This service scored 56 (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.

The provider had not fully considered people’s safety and well-being when supporting people to move into the service. One person was supported to move into the service with needs that were known to cause distress to others. This meant that people whose care records noted situations which could make them anxious, were repeated exposed to those situations.

The provider reviewed accidents and incidents at the service. These had increased due to an unsuitable placement. Accident and incidents were reviewed by the registered manager and head of area, as well as the provider’s quality assurance, health and safety and behavioural support teams. This enabled a thorough analysis of events, to determine their causes and develop action plans to prevent recurrence. Risk assessments and support guidelines were regularly updated following incidents, and referrals were made to health and social care professionals for specialist input. Lessons from events were discussed with the staff team during meetings.

The provider did not always work well with people to make sure there was continuity of care, including when people moved between different services.

The provider had not fully considered the compatibility of people when developing the service. One person was supported to move into the service (as an emergency placement) with needs that caused distress to others. Whilst the person’s specific needs had been assessed and additional agency staff deployed to support the person, the provider had not taken into account the significant impact on other people living at the service.

People, their relatives and staff were not consulted about the transition, and the person did not get the opportunity to get to know the service before resettling. One member of staff told us the person, “Should have been visiting over many days before moving in.” This meant people experienced on-going disruption and anxiety due to a foreseeable and avoidable, incompatible mix of people living in the service.

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.

People were supported by staff who were trained to protect them from abuse, avoidable harm and improper treatment. However, whilst the provider had safeguarding procedures in place which staff understood, the provider exposed people to the risk of harassment and avoidable harm by moving people into the service who were incompatible.

Staff knew the signs and risks of abuse and told us the actions they would take if they suspected this. These included informing the registered manager. Staff also understood the provider’s whistle-blowing procedure. This was a process that encouraged staff to report to the local authority safeguarding team or CQC any concerns they had about people’s safety, if the provider failed to address them.

Where safeguarding concerns had arisen, the provider worked collaboratively with the local team to investigate them. The provider acted transparently during investigations and acted upon their findings.

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 where people were subject to restrictions to keep them safe, details of the deprivation, the assessments supporting them and the duration for which they applied, were stated in care records. This meant that people were treated in line with legislation.

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 that mattered to them.

Risks to people’s safety and wellbeing were not always managed in a person-centred way. Some people expressed themselves in ways that could be distressing for others. The provider failed to identify or assess the impact of this. Some people’s quality of life had been reduced because they retreated from certain areas of the home and declined specific activities to avoid exposure to unsettling incidents.

People were involved in the development and implementation of their risk management plans. For example, people discussed, agreed and practiced road safety risk management plans to ensure they were safe in their community. When required, people were supported to have the safety of their swallowing assessed by healthcare professionals. Staff followed the guidance from these assessments by ensuring people ate food and consumed drinks at the consistencies prescribed to prevent choking.

Staff ensured that risks within the environment were assessed and mitigated. They maintained a readiness to respond to fire emergencies by regularly testing alarms and sensors and practicing building evacuations. Staff undertook food safety training to protect people against the risks of unsafe food storage, handling and preparation. Similarly, staff were trained to follow appropriate infection prevention and control practices to keep people safe.

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 provider ensured the environment of the care home was safe. The registered manager reviewed a range of health and safety checks including the health and safety, food safety and fire safety. Where required specialists undertook safety checks. These included electricity, gas, emergency equipment and water safety checks.

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.

People were supported by staff who were recruited through robust processes. Prospective staff completed an application and attended an interview. Successful applicants had employment references taken up and the provider undertook identity, criminal record and right to work checks. New staff completed an induction and probation period after which their employment status was confirmed.

The provider ensured there were sufficient numbers of staff deployed to keep people safe. The level of staffing was based upon people’s needs and agreed in partnership with commissioning authorities. The service was staffed 24-hours a day, with staff divided into shifts.

People were supported by trained staff. The provider ensured that staff received on going training. This covered a range of areas including health and safety, first aid, safeguarding and medicines. Staff also received training to support people’s specific needs. For example, staff received training in positive behavioural support. This training focused on communication with people, promoting their independence and managing distress. This meant that people were supported by staff with the skills and knowledge to provide care and support.

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.

People were protected from the risk and spread of infection. The provider had up to date infection prevention and control procedures which staff were trained to follow. Staff wore appropriate personal protective equipment when providing personal care. Additionally, staff were trained in food safety and followed appropriate practices when storing, preparing and serving food.

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.

People received their medicines safely from staff who were trained to administer them. Staff recorded the administration of medicines appropriately and the registered manager audited medicines records. People’s medicines were stored safely and securely and reviewed by the GP to ensure they remained necessary and effective.