Adel Grange Residential 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

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 assessing and managing risks to people.

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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Leaders did not always embed improvements and development to learn from incidents. While leaders shared learning with staff to minimise the risk of an event happening again, we found some incidents, such as some people falling, were not risk assessed. This meant there was not an understanding on how to reduce future falls. The provider worked to analyse accidents and incidents and this was in a a clear and methodical way.

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.

The service had a good working relationship with health professionals such as GPs and district nurses to make sure people received the right support at the right time. One visiting professional told us, “I have been coming here for a long time and I have never seen anything to concern me.”

The provider 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. The provider did not always share concerns quickly and appropriately.

Not all staff had a sufficient knowledge of how to safeguard people from abuse. From the staff we spoke with, some had an understanding of safeguarding and knew what it meant, while others didn’t. One member of staff told us, “Safeguarding is about abuse and neglect.” While another member of staff told us, “Safeguarding? It’s about the bullying of staff. I don’t know. I would just tell the manager.” However, we found staff had been trained in safeguarding and the provider raised safeguarding concerns with the local authority and informed the Care Quality Commission.

Not everyone had their risks identified and assessed. This meant not everyone’s risks were managed and reduced to ensure their safety. For example, one person was at high risk of falls. They were admitted to hospital as a result of falls and needed ambulance attendance following falls on other occasions. There was no falls risk assessment in place for this person. Staff did not have the guidance to understand how to minimise risk of future falls and what to do in the event of a fall. However, staff felt they had enough information. One member of staff told us, “The care plans tell me what I need to know. The care plans for permanent residents are the same as the short stay ones.” However, people told us felt safe living at the service. One person told us, “This place is perfect. The staff explain what they are doing.”

The provider was in breach of the legal regulation relating to the assessment and management of risks.

The provider did not always detect and control potential risks in the living environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Fire risks were not safely managed. We found bedroom fire doors propped open by chairs which prevented the door from closing which increased the risk of fire spreading in the event of a fire. We also found fire drills were not routinely completed and some staff had never completed a fire drill.

The provider was in breach of the legal regulation relating to the safe management of fire risks.

The provider enough staff, who received regular support, supervision and development but not all staff had the skills on critical areas such as safeguarding, managing risks and fire safety. They worked together to provide safe care that met people’s individual needs.

There were enough staff to provide safe care to people but staff were not always skilled to keep people safe. Some staff we spoke with did not have a fundamental understanding of safeguarding adults and fire safety. Some staff we spoke with had never participated in a fire drill or could remember when they last did one. However, we found there was consistent staffing without the reliance on agency staff, which had a positive impact on people who received care from staff who knew them well. We found staff had been trained in key areas such as the care certificate. People felt there were enough staff at the service. One person told us, “There are plenty of staff. You don’t have to wait long.” A staff member told us, “There is enough staff, yes.”

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 were audits and checks in place which helped to provide oversight of infection control. Housekeeping staff worked hard to ensure the service was kept clean. We observed staff using personal protective equipment (PPE) throughout the inspection and staff were found to consistently wash their hands before and after caring for someone. One person told us, “I have a lovely bedroom and the place is always clean. The staff are clean.” Another relative told us, “This place is absolutely spotless. Staff wear PPE and the place is always warm.”

The provider did not always make sure that medicines and treatments were safely managed and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medication was not always safely managed. We found protocols to inform staff when people needed “as and when required” medication (PRN) were not detailed or person centred. For example, one person needed paracetamol when they were in pain. The protocol did not identify where the pain would be, how the person would communicate the pain and what to do if the pain did not resolve. We also found not all creams were labelled with the date when they were opened.