Allambie House

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 the ways people’s medicines were managed safely.

This service scored 50 (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. Lessons were not always learnt to continually identify and embed good practice. The registered managers understood their responsibility to be open with people and their relatives when errors or omissions had occurred. One relative told us, “The home told me [Name] slid off the bed about 9 months ago. I am very happy they dealt with it properly and it has not happened since.” Staff understood the process for recording and reporting accidents and incidents in the home. One staff member explained how they explored the cause of accidents to identify where improvements could be made. This staff member told us, “When we are in the room dealing with an incident, we will discuss how that person had a fall and let the management know.” However, systems for ensuring opportunities for taking learning from incidents reported needed to be further strengthened. For example, accident forms and the registered managers’ analysis did not always provide details of circumstances leading up to accidents and there were inconsistencies in exploring what, if any injuries had occurred, or if external health professionals had been contacted after accidents. The registered manager’s oversight did not consider if any lessons learned had been considered, or changes in people’s needs identified. We also found an error by staff when entering a date on an accident form. This had not been identified by the registered managers or provider and meant an accurate picture of the falls one person experienced over time was not recorded and analysed. This increased the likelihood learning would not be effective and appropriate referrals to other health and social care professionals would be delayed. In addition, staff did not always recognise their role in reporting poor practice to promote and share learning. For example, staff responsible for medicines administration had not reported gaps in medicines records.

People did not always benefit from a consistent approach to reducing their risks when transferring between services. The provider’s electronic care planning system enabled staff to generate a ‘hospital pack’. The registered managers told us hospital packs would be sent with people when admitted to hospital and included a summary of people’s key risks and general care needs. However, conversations with staff indicated this was not embedded in staff practice. This presented a risk of people being provided with unsafe care due to a lack of shared information. Some staff approaches to communicating information were working more effectively. Some people living at Allambie House had a learning disability and had individual hospital passports. Staff understood the importance of these documents to ensure hospital staff had information about the person’s health and how they liked to communicate. Staff told us any changes in people’s needs following a hospital visit or admission were shared on people’s return to the home. One staff member explained, “The senior on shift will review the discharge letter detailing the information, what happened, any change in medication and we will inform the staff on shift. It will then be passed on immediately to the manager.” Systems ensured people did not miss important medical appointments, and where necessary, transport and escorts were arranged.

The provider raised and shared safeguarding concerns appropriately, but staff knowledge of safeguarding processes needed to be improved. Staff had received training in how to safeguard people and knew how to identify potential abuse. Staff told us they would not hesitate to report any concerns and were confident the registered managers would take action to protect people. However, we found some staff did not know the range of external organisations they could contact to escalate safeguarding concerns. For example, local authority safeguarding teams and the police. People told us they felt comfortable in the home and safe with the staff who provided their care. One person told us, “The staff always look after me, I love them a lot.” Another person commented, “I’m quite safe. If there was a problem I would speak to one of the girls.” A relative told us, “I have no concerns for [Name’s] safety, none whatsoever. They love it here.” Where people’s human rights were restricted and detailed within their care plan, applications to deprive people of their liberty had been submitted.

The provider used some recognised assessment tools to identify people’s risks in areas such as weight management, preventing skin damage and mobility. Care plans were developed to mitigate identified risks. People told us they felt safe and shared no concerns about the care they received. One person commented, “I am very happy with the support I get.” Another person told us they could be as independent as they wanted to be, but staff were available when they needed assistance. This person explained, “Sometimes I get up by myself. This morning, I couldn’t get up, so they came and helped me.” We saw people had their call bells to hand so they could call for assistance and staff ensured people had mobility equipment close to them. However, we found ‘one off’ assessments in relation to specific risks required further development. For example, one person wished to self-medicate. The impact of the person not taking their medicine had been assessed as minimal, but it would have had a significant or major impact on the person’s health. This meant we could not be assured the right level of risk had been identified. In addition, the provider needed to further develop how they assessed and managed risks to people when eating, so this followed best practice standards such as IDDSI, [International Dysphagia Diet Standardisation Initiative], to further reduce risks to people.

The provider detected and controlled potential risks in the care environment. The provider had ensured there was sufficient staffing resources and expertise to make sure checks were regularly undertaken on safety of the premises. Staff told us they had access to the equipment needed to provide care to people. Regular checks were undertaken on the safety of the premises and equipment. Where actions had been identified, these were promptly actioned.

The provider made sure there were enough staff. However, processes to assess the effectiveness of training on staff practice needed to be improved. People told us staff were available when they needed them. Comments included: “I’m happy with the numbers of staff”, “To be honest there always seems to be plenty of staff on” and, “I have a call bell, they come quite quickly usually.” Staff told us staffing levels enabled them to provide the care outlined in people’s care plans. Staff received an induction into the service and were provided with some opportunities to refresh their training and knowledge. However, we found the provider needed to introduce more robust processes to assess the effectiveness and impact of training on individual staff practice. This was because conversations with staff demonstrated some gaps in their understanding, for example in relation to safeguarding, medicines management and the Mental Capacity Act 2005. Improvements were also required in the way the provider ensured staff fulfilled their expectations in relation to the frequency of training undertaken. This would help to assure the registered managers and the provider that staff continued to develop their skills and kept up to date with best practice standards and provided safe care. Systems were in place to safely recruit staff and to check the suitability of temporary staff proving care to people. However, we found an instance where a staff member’s previous employment had not been fully explored.

The provider needed to develop a more robust approach to managing the risk of cross infection. Staff told us they were able to access the PPE [personal protective equipment] they needed to provide safe care to people. However, we found some practices to support good infection control could be improved. For example, water jugs were not dated to ensure they were changed frequently, and two commodes were seen to be visibly rusted which made them difficult to clean. In two areas of the home, we saw aprons had been left over handrails which increased the risk these items would not be clean before use. One person had been unwell the night before our second visit which could have been an indicator of a potential infection. Domestic staff had not been told, so they could adapt their cleaning schedules to reduce the risks of infection spreading. Overall, the home was clean and tidy, but checks on infection prevention were either not robust enough or frequent enough to identify soiling of covered radiators with some bathrooms and the hairdressing area containing porous surfaces, which would make them difficult to clean. Most staff had training in infection control practices and food hygiene, but some staff had not benefited from receiving this training. Other staff had not had the opportunity to regularly update their skills. People did not raise any concerns about infection control standards in the home. Comments included: “They clean my room every day” and “They clean my room regularly; I am happy with it.”

The provider's records did not demonstrate people received their medicines as prescribed or that the provider was working in line with national medicines guidance. One person was prescribed medicine 'as required' to manage their levels of anxiety. Guidance was not available to inform staff when they should give the medicine. Staff had given the medicine as a regular dosage and not recorded why it had been given to enable any triggers to the person's anxiety to be identified and ensure this was managed effectively. There was a risk the person may receive sedation when this was not necessary. Guidance was not in place to inform staff when medicines prescribed 'as required' for pain relief needed to be given. This meant people could be given too much or not enough of those medicines. One person was prescribed a medicine to be given via a transdermal patch applied to their skin. It is important patches are rotated around the body to avoid people experiencing unnecessary side effects. There were no records to confirm old patches were removed prior to a new patch being applied, or to advise of the application site of the new patch. There were gaps on Medicines Administration Records (MARs) where staff had not signed to confirm people had received their medicines. Handwritten amendments to MARs had not been signed and countersigned by 2 staff to confirm their accuracy. Where people were prescribed variable doses of medicines, staff were not recording how much medicine had been given. One person declined to take their medicine in front of staff. There was no risk management plan or system of checks so the provider could be assured the person was taking their medicines. Staff had not recorded the time they administered medicines to people. This increased the risk people may not benefit from the therapeutic medicines they wanted, or increase the likelihood of people being overmedicated. Staff completed medicines training, but night staff had not had their competency assessed.