Aran 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

Accidents and incidents involving service users were not consistently investigated and action taken to keep people safe, in a timely manner. The provider had failed to ensure their own accident and incident policy was consistently followed. This meant opportunities to learn from these events and reduce the risks to people were lost. People’s rights under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) were not fully understood by staff which meant people were at risk of being subject to restrictions which were not proportionate or in their best interests. This was a breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that despite staff being aware of the risks to people, what they told us about risks to people was not consistently recorded in people’s care plans and, in some cases, risk assessments were also missing. People’s risk assessments were generic, and not person-centred. This meant staff were not consistently provided with the most up to date, detailed information on how to support people safely and effectively. People told us they felt safe and that there were enough staff to support them and respond to their needs. People were supported to take their medicines safely. Although the people we spoke with expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards. The provider took on board all feedback given during the assessment process and were in the process of producing action plans to address the concerns raised.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives told us staff knew them well and they knew how to speak up if they had any concerns regarding their safety. A relative said “They [care staff] are fully aware of [person’s] needs, and they keep me informed of their condition.” Relatives told us they were kept informed of any changes in their loved one’s needs. They told us they knew who to speak to if they had any concerns regarding their loved one’s safety.

Staff were aware of the need to report any accidents and incidents and were confident appropriate action would be taken. Staff were aware of the risks to people and told us they were kept informed of any changes in people’s care needs. However, due to accidents and incidents not being consistently reviewed in a timely manner, the provider could not be confident staff were provided with the most up to date information in order to provide safe and effective care. For example, lessons learnt following an incident were not shared with staff in a timely manner, placing 1 person at potential risk of harm.

The provider’s own policies and procedures with regard to safeguarding, reporting and acting on accidents and incidents and dealing with complaints, were not consistently followed. This meant opportunities to learn lessons from these events were lost, placing people at potential risk of further harm. Investigations into accidents and incidents had not been completed in a timely manner. For example, we saw 4 instances involving 3 people where reviews of incidents had not taken place. This placed these individuals at potential risk of further harm and meant staff were not provided with the most up to date information on how to support people safely and effectively.

People told us they were able to access a variety of healthcare services to meet their needs and the equipment they needed was available to assist them.

Staff spoken with told us they were provided with the information they needed when people were first admitted to the service and would then work with colleagues to build up a picture of people’s needs. Staff told us they worked well with colleagues and other professionals as people transferred between services.

Other partners advised they worked well with the provider and had effective levels of communication in place.

For those people moving into the service, there was a process in place which involved gathering pre-assessment information regarding the individual. Healthcare partners involved in this process reported staff followed the appropriate procedures to ensure the smooth transition of people into the service.

People told us they felt safe. One person told us, “I feel safe because they [care staff] come round and check when you’re in bed.” However, a relative raised concerns regarding the length of time it had taken to investigate an incident involving their loved one. The provider’s response to safeguarding incidents was not always timely and important lessons to be learnt were not acted on immediately, placing people at potential risk of further harm.

Staff told us the process they would follow to raise any safeguarding concerns, mainly by informing the manager and were confident the manager would raise their concerns on their behalf. However, not all staff were aware of local safeguarding procedures and who to report to in the absence of the manager or if concerns related to the manager and/or senior management team.

Safeguarding systems, processes and practices were not consistently applied to ensure people were protected from abuse and neglect. A social worker reported a safeguarding incident that came to light following a visit to a service user. They were concerned action was not taken in a timely manner in response to this incident and had reported their concerns directly to the manager. Accidents and incidents reports were not consistently reviewed in a timely manner. One relative had raised concerns via a complaint which had not been dealt with in a timely manner. Another relative raised concerns regarding the length of time it took to obtain some answers regarding an incident and actions were not taken immediately to reduce the risk of reoccurrence.

People told us they felt the risks to them were managed well. One person told us, “I’d rather be at home, but I’ve had so many falls it’s safer here. They [staff] look in when they are walking past – they keep an eye on me”. However, people could not recall being involved in reviews regarding their care or discussions about how to manage the risks to them. Relatives spoken with reported they were contacted following any accidents or incidents involving their loved ones and told us they had been involved in reviews in the past with social workers but could not recall being routinely involved in reviews of their loved ones’ needs. They told us there had not been any regular face to face meetings to involve people, themselves or support staff, but those who visited regularly told us they were in regular contact with staff.

Staff were able to explain the risks to a number of people and how they supported them safely to manage those risks. However, what they told us was not consistently recorded or reflected in people's care plans and risk assessments. For example, an investigation into an incident where 1 person had suffered a fall had not been completed in a timely manner. When staff were spoken with regarding the incident and any actions taken following this, they provided conflicting information regarding how to support the person safely. The lack of consistency in staff’s response to this incident placed the person at potential risk of further harm. Although staff were able to provide some detailed information regarding people, it was not always documented in care records, meaning people could receive inconsistent and potentially unsafe care.

We observed people were encouraged to maintain their independence and walk around communal areas freely, without restriction. We observed staff to use safe moving and handling practices.

Risks to people were not always assessed and risk assessments around their care were not consistently person-centred. This included the failure to assess and manage risks associated with people’s specific health conditions, such as Parkinson’s disease. Risk assessments contained limited information on how to manage individual risks. There was a lack of evidence to demonstrate people had been given the opportunity to discuss the risks to them or be involved in reviews of their care. There was a lack of effective oversight of the current risks to people. Clinical risk meetings were taking place to review the risks to people but had not identified or reported on some of the areas of risk found during the assessment.

People considered their living environment to be safe, bright and clean. One person said, “What I like about this place is that it’s really clean. As soon as you come in you can see how clean it is from the smell.” People told us they felt safe living at Aran Court and were provided with the equipment they needed to maintain their safety.

The provider reported improvements were planned in the environmental living standards of the dementia unit in order to improve the quality of life for people living there. The unit was not dementia-friendly. The provider outlined their plans for improvement of the service and the environment and work had commenced during the assessment.

Maintenance systems were in place. However, a complaint about the service raised concerns regarding the length of time it took to get a light fixed in a bathroom. Environmental checklists were in place as part of the manager’s daily walkarounds. We identified concerns regarding the validity of the legionella certificate seen during the assessment and outstanding actions that needed to be taken. Assurances were received during feedback with the provider that the correct certificate was in place and all actions had been taken.

People told us they felt there were enough staff to meet their needs. One person said, “What I like about this place is I feel secure here. There is someone always around and we are well looked after. Staff always come quickly when you press the buzzer.” A relative told us, “There’s plenty of staff and they are really friendly. They are fully aware of [person’s] needs”. People and relatives felt the staffing arrangements at the service had significantly improved under the current management team.

Staff told us they felt there were enough staff most of the time, and staffing levels had improved recently. One member of staff commented, “We have enough staff. We used to have some days just 4 staff [on a particular floor]. You seem to have a lot more time for the individual [now] because there are a lot of residents who like the company. [There’s] more time with personal care as well.” Staff told us their induction included shadowing colleagues and mandatory training, but did not include dedicated time for staff to read people's care plans. Staff reported this would be beneficial. We shared this with the management team who confirmed this would be looked into. Staff told us they felt well trained, but staff spoken with were not aware of who had a current DoLS authorisation in place. This placed people at potential risk of being unlawfully restricted. Staff confirmed they had not received any additional dementia care training, which they felt they would benefit from. Management had identified the need to carry out training needs analysis of staff across the service and plans were in place to provide staff with more training around supporting people who displayed distressed behaviours. Staff confirmed they had recently had a supervision with the manager and were provided with the opportunity to raise any concerns they may have.

We observed people had positive relationships with staff and approached staff for support. We saw staff responded promptly to call bells and were present to offer support in communal areas including corridors.

A dependency tool was in place to assess people's needs and ensure appropriate staffing levels were in place. The manager explained this was reviewed on a regular basis and was able to evidence changes made in staffing levels to accommodate changes in the number or needs of the people supported. We were told by a member of the management team that the dependency tool in place was in the pilot phase and the service was in the process of completing and reviewing the current information. Staff competency checks to ensure staff supported people safely and effectively were ongoing. Where work in this area was outstanding, arrangements were in place to address this. People were supported by staff who had been safely recruited. We saw systems had now been put in place to monitor staff supervisions and competencies.

On the whole, people supported by the service and their relatives told us they were happy with the support they received to take their medicines safely. People told us they received their medication as prescribed. However, a concern was raised by a relative regarding an incident where medication protocols were not followed, placing their loved one at risk of harm. This was being investigated at the time of the assessment.

Those staff spoken with who were responsible for supporting people to receive their medicines, told us they felt well trained. Staff used an electronic system to record when people had received their medication. The management team advised staff received medication training at induction as well as refresher training. Staff were not aware of the impact of a particular drug on people and the potential to place people at risk of falling. The provider told us they would carry out a review of people’s medication and their care and risk assessments in light of this. The provider reported at our feedback meeting with them that this work had been completed.

Electronic medication administration records were kept demonstrating when people had received their medication. People’s medication records detailed how they liked to be supported with their medication and protocols were in place for ‘as required’ (PRN) medication. Medicines were stored safely and in line with good practice. Medication audits took place to across the service and for each individual on a monthly basis.