Arbory Residential Home

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• 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

We assessed a total of 7 quality statements from this key question. We identified 3 continued breaches and a new breach of the legal regulations. During our assessment of this key question, we found systems and processes in place to ensure safe care and treatment were not always effective. The provider had failed to ensure potential risks to people were assessed and mitigated. We found concerns with the management of infection prevention and control, several areas were unclean, and foods were not always stored appropriately. Not all aspects of people’s medicines were managed safely. We found concerns with the environment, doors which should have been locked, for people’s safety, were found to be unlocked. We found recruitment of staff was not always safe and people were not always engaged in meaningful activities.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Five out of 7 relatives we spoke with told us they did not feel listened to when they raised concerns with the provider. Their comments included, “I did raise concerns but felt I was not being listened to,” and, “I have spoken about unsafe incidents to [One of the management team] who is yet to give me any feedback and plans of action.” Following the assessment the provider told us they were improving their complaints monitoring systems.

The management team were able to describe how they learnt from complaints, safety related concerns or near misses. They told us they discussed this with staff in their support and supervision meetings. Records showed staff did not receive regular support and supervision in line with the provider’s policy and therefore the opportunity to learn from complaints was reduced. However, we did see, when a significant medicines incident was found following the provider’s investigation, all staff received a reflective supervision and were retrained in medicines administration. The management team told us while they wished the medicines incident had not occurred, they were confident they had managed the matter effectively and they had an effective process in place to deal with safety related concerns or near misses. Feedback from staff was mixed, some staff members told us they did not feel the service encouraged them to raise concerns. They told us they had the standard training when they started at the service in relation to whistle blowing and accessing the Speak Up guardians, but when they raised general concerns, it did not work in practice as they felt their concerns were not always responded to and that they had to remind managers again. Following the assessment the provider told us regular staff supervision were put in place to support staff’s development.

A culture of safety and learning was not always evident. A staff member told us feedback, following incidents, was only provided to senior staff. A member of the management team confirmed this. We saw some incidents which related to falls had incident forms which were fully completed, suitably detailed and were reviewed by the deputy manager. One person had several falls in quick succession, we could see a falls analysis was completed and a referral made to the fall’s clinic. However, for another significant incident this did not happen. Falls analysis for 2 other people also did not clearly show the action taken to reduce the risk of recurrence and injury. We had to ask staff to confirm whether referrals to health professionals had been made as this could not be determined from the records. Inaccurate incident management increased the risk of incidents recurring placing people at risk of harm. Records showed when things went wrong, staff apologised and gave people honest information and suitable support. The provider had a complaints and compliments folder in place, the last recorded complaint was 30 August 2023. We spoke with a member of the management team who told us complaints and compliments were documented daily in flash meetings. We reviewed the flash meetings and found evidence of complaints being discussed however, the record did not show if or how the complaints had been resolved. Another member of the management team told us responses and learning from complaints were not documented following discussion in the flash meetings. Staff could therefore not determine how concerns and complaints were responded to and what learning they needed to take from these. Following the assessment the provider shared updated documents including an incident trend analysis and a safeguarding log to support their monitoring of incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives had mixed views about people’s safety. Some relatives told us they did not think people were safe living in the home. One relative said, “Safeguarding issues have been identified, such as the staff not providing my [relative] with her medication, especially for her diabetes.” Some relatives told us people had been assaulted by another person who goes into their room. Other relatives we spoke with felt people were safe in the home. All relatives told us they would raise their concerns with the manager. Some relatives told us they did not believe their concerns were listened to or acted upon. Other relatives felt staff had listened to them when they had raised concerns.

The management team was able to describe the process for reporting safeguarding concerns to the local authority’s safeguarding team and CQC. They worked in partnership with the local authority when dealing with a safeguarding concern and told us they responded to information requests and were supported by their Nominated Individual and the wider team. The Nominated Individual is responsible for supervising the management of the service on behalf of the provider. They told us, “We do quizzes following training.” One of the leaders told us, “Safeguarding is a topic of conversations in supervisions.” The deputy manager told us, “We also speak about whistleblowing and how to report it.” We could not be assured this information was always discussed because there was a lack of regular supervisions. The management team and staff told us restraint was not used in the home. Staff told us they attempt to redirect or distract people when they were at a heightened state of anxiety. Staff members were confident that leaders would take safeguarding concerns seriously and respond appropriately.

People were observed to be dressed in clean, weather appropriate clothing. A family member commented their relative was always well dressed and liked to wear their jewellery. We saw their relative, at lunchtime, was well-presented and wearing their pearl earrings. Other people were wearing jewellery and had nail varnish on. Staff were observed to maintain positive body language with good eye contact and people seemed comfortable with the staff supporting them. We observed staff interacting well with people. Staff were respectful when talking to people and were patient and helped where needed. We were asked to show our ID badges when we arrived on site and asked to sign in the visitor’s book which demonstrated the provider ensured only authorised people could enter the service. We observed Speak Up posters in prominent positions around the service.

Systems, processes and practices were not always effective at ensuring people were protected from the risk of abuse. For example, we reviewed an incident form detailing an incident which put a person and others at risk of harm. A follow up was required to safeguard people however, the handover to staff at shift change was not effective. The incident was only resolved after 21-day days when we brought it to the provider’s attention. Following our onsite visits, we had feedback from a professional who visited the service. They were concerned the provider had not raised safeguarding concerns with the local authority’s safeguarding team where they were required. The management team were not aware of all the incidents and had therefore not reported them. These incidents were recorded in people’s record of support notes however, had not been reported to the management team or CQC. Systems and processes in place failed to pick up when incidents occurred that required referral to other agencies. This meant the local authority and CQC was unable to monitor and assess if safeguarding situations were being dealt with appropriately. The provider had since submitted retrospective notifications and the professional raised safeguarding alerts. All the staff had received a reflective practice supervision following a recent medicine safeguarding concern. The provider retrained all staff in the administration of medicines and safeguarding. A new system was put in place for signing in medicines and a daily management oversight document put in place to check all medicines had been given on each shift. The provider had an up to date safeguarding policy in place and staff had received safeguarding training. Following the assessment the provider told us of the actions they were taking to strengthen safeguarding systems.

Most relatives told us they were involved in people’s care plans and risk assessments when they first moved into, the home however, this had not been an ongoing process. Some relatives told us they felt people were not supported to manage risks such as their dietary needs relating to their diabetes.

We were not assured risks were understood to ensure care met people’s needs in a safe and supportive way. We spoke with the management team and the Nominated Individual about diabetes management. Menus contained lots of carbohydrates which would have an adverse effect on people who had diet-controlled diabetes. The deputy manager told us they would devise a new menu, however the examples they sent us remained carbohydrate heavy. This demonstrated a lack of understanding about the diet required for people who had diet-controlled diabetes which increased the risk of their blood sugar becoming unstable. Care staff and the cook did not always understand who had Speech and Language Therapy (SaLT) guidelines in place and required their food to be modified to reduce their risk of choking. A staff member told us care plans were mostly out of date, but seniors were working to try and get them updated. Staff demonstrated they understood the correct process for hoisting people. Following the assessment the provider told us they had reviewed people’s eating and drinking guidelines including information about the consistency of people’s food.

We observed a person being hoisted in accordance with their risk management plan. They were being talked to and staff explained what was happening throughout the transfer. All staff had received manual handling training. People were supported according to their care plans at mealtime. Where one person had food which required pureeing it was presented separately to make it look more appetising. We observed staff supporting people to eat when required, in a relaxed and interactive manner. Staff members conversed with people who were eating their meals. Staff asked people if they could clear their plates and offered more drinks. When people appeared reluctant to eat staff gently encouraged them with good success. When people finished their meals, we observed staff supporting those who were standing up by either getting their walking aids for them or walking with them.

Where people had health conditions, their care plans to mitigate risks contained contradictory information or lacked detail. This included a lack of information about when to use constipation medicine and dietary guidance for people with diet-controlled diabetes lacked detail. People’s skin integrity was not always managed effectively. Records showed people did not always receive pressure relief in line with their care plans. Other people were not checked on at the intervals specified in their care plans. People did not always have access to sufficient fluid at all times putting them at risk of becoming dehydrated. Some people had their last drink of the day recorded between 5 pm and 6 pm and fluid intakes were low for some people. Some questions in risk assessments were not answered. This meant the outcome of the assessment was not always accurate in determining people’s risks. Some assessments contained conflicting information, for example, 1 assessment stated the person was independent with a walking aid however, in the same document it also stated the person was unable to mobilise safely with their walking aid without support from staff. Conflicting information was confusing for staff in particular inexperienced staff and agency staff would not have the guidance needed to support people safely. We spoke to the management team about our concerns. They updated care plans in the areas we told them about during the assessment. Following the assessment the provider told us they were strengthening the monitoring of people’s risks and reviewing risk management plans.

People’s relatives told us on the whole they thought the environment was safe. However, they felt the outside garden space was not sufficiently safe for their relatives to use. We looked at the garden. Large areas of the garden were fenced off due to work that was taking place to put solar panels on the roof. The small area of the garden people had access to was safe, with no uneven paving slabs or overgrown areas.

A member of the management team told us fire drills took place every 6 months to include both night and day staff. We spoke with the staff member who carried out fire door checks. They told us, doors were checked weekly however, there was no record of this or what action was taken if concerns were noted. This meant the provider may not be aware when outstanding work had not been completed putting people at risk of harm. It was not clear which zones had been checked on testing fire alarms from available records. We spoke to the staff member who carried out fire alarm tests who confirmed this was not always recorded. During the assessment the form was updated to ensure all zones would be checked going forward. The failure to record which zones were checked meant the provider was unable to determine if all zones had been checked regularly. After our assessment the provider confirmed these records were now in use, checked by the manager and the service had received a positive fire service visit in June 2024. Staff told us they received fire training and had taken part in fire drills. The manager told us water pots were usually in the kitchenette fridges on each floor for testing fridge temperatures. A staff member told us, “We haven’t had water pots in our fridges for nearly 6 months.” We saw there were no thermometers in the kitchenette fridges. This meant the provider could not accurately record fridge temperatures to monitor safe temperatures for food storage which could put people at risk of harm.

The environment was not always safe. We checked several fire doors to establish if they closed on the fire alarm sounding. Four of the doors did not close fully. The staff member responsible for fire safety was aware 2 doors were not closing and had reported them for repair. They were not aware of the other 2 doors not closing. They told us they would report them straight away. Cleaning products were not always stored safely. On 16 April 2024 we found the lock to be broken on the cupboard containing COSSH products in the kitchenette area on the top floor. This was rectified by 18 April 2024 however; on 23 April 2024 we found a cupboard containing COSHH products was unlocked in the ground floor kitchen dining area which meant people had access to potentially harmful substances. In most people’s en-suite shower rooms the ceilings were stained with water damage. Shower heads had not been descaled on the ground floor and first floor and were heavily covered in limescale. The Health and Safety Executive (HSE) states, shower heads should be cleaned and descaled at least quarterly to reduce the risk of legionella growth. Following the assessment the provider sent pictures to show this had been addressed. A door was unlocked and people could access an area where building materials were being kept and the stairs. We spoke to the deputy manager about this. They told us the door does not always lock if it is not pulled hard enough. They told us there was a sign on the door to remind people to close it however, we found there was no sign on the door. Many people lived with dementia, we could not be assured they would not access this doorway, the building materials or potentially climb the stairs unaided. The failure to effectively assess, monitor and mitigate the risks to this door being unlocked put people at risk of harm. Following the assessment the provider told us ceilings had been painted, shower heads descaled and fire doors and locks replaced and repaired.

Systems and processes in place to maintain a safe environment were not always effective. For example, although 1 staff member told us fire doors were checked there was no record that this took place and there was no record of what action had been taken when fire doors were found to be defective. This placed people at risk if a fire was to occur. We found other fire checks were completed such as weekly fire extinguisher checks, regular fire alarm tests as well as regular fire drills. The provider’s audits had not picked up the concerns we found during assessment in relation to access to building materials and stairs, cleanliness of kitchen and dining areas, unlocked cupboards containing medicines and unlocked COSHH cupboards, shower heads covered in limescale and fire doors not closing fully. Risk assessments had not been put in place to reduce the risk of, for example, the defective fire doors whilst repairs were being undertaken. One of the management team told us they complete a daily walkaround however, they had failed to identify the concerns we observed on assessment or take action to address the risks. The provider’s maintenance file contained a gas safety certificate, emergency lighting test certificate, electrical installation certificate as well as fire equipment servicing, electrical testing and manual handling equipment safety certificates, these were all in date. Following the inspection the provider told us of action they have taken to support for example the monitoring of fire and water safety.

Relatives told us they did not think staffing was always safe or effective. Some relatives told us staff could be insensitive at times. Some relatives told us they were not confident staff were sufficiently skilled to ensure people were drinking enough, to manage people’s personal care or their dementia related needs. Other relatives felt staff had the right skills and knowledge to support their loved ones to achieve the best outcomes for them. Most of the relatives we spoke with told us they did not think there were enough staff. Some of their comments included, “We tend to sit in the dining room, but staff are not always around when needed,” and, “I don’t think there are enough staff on the floor. It seems that there are only 2 staff members when there should be 3 members on the floor with quite a few, very vulnerable residents.” Relatives were also concerned about the lack of activities available for people.

Staff raised concerns about night staffing ratios. They told us they were concerned if 2 people required 2 staff to support them at the same time this could not be done safely. They were concerned if there was a fire it would be unsafe, or if someone fell during the night this could lead to other floors being left without staff. We asked staff about the provider’s training programme. Staff told us the moving and handling training could be better as well as the online fire training. Staff told us they struggled to provide care using slide sheets and manual handling training was inadequate. They told us training was online and felt in person training would be better. The deputy manager told us they ensured best practice was followed by observing staff and staff were only asked to undertake tasks when they had the necessary skills and experience. They told us new starters had, “3 shadow shifts and get manual handling techniques.” They told us if people need more than 3 shadow shifts this was accommodated. Most staff members told us they had not had regular supervision. Two staff members told us they had never had a supervision. The management team told us they used a dependency tool to calculate how many staff were required and assessed staff’s competency in medicines and moving and handling practice. They told us following induction new staff had reviews to ensure staff had been inducted effectively.

There were not always enough staff to plan and provide meaningful engagement for people. There was no activity coordinator in place. Staff did their best given the time available. We observed 1 staff member reading with a person and another staff member doing colouring with 3 people. However, this left a lot of people who did not receive any meaningful engagement for long periods of time. The provider told us they were in the process of recruiting an activity coordinator. At night there was 1 carer allocated to each of the 3 floors with one senior carer on duty. The senior carer administered medicines on all 3 floors so were not available for approximately 1 to 2 hours from the start of their shift. The provider told us they believed staffing ratios were above what they had assessed were required to be within the home. The deputy manager was supernumerary during the day, to allow dedicated time to the service’s management and delivery plans. We observed staff were friendly and engaged with people during their routine interactions. We observed 2 staff carrying out a transfer using a hoist. We observed this was completed appropriately and safely and staff informed the person what was happening throughout this procedure. Following the assessment the provider told us staffing had increased to 5 staff members at nighttime as a minimum as a result of a review on people’s needs.

At our last inspection and this assessment, we found recruitment records did not always include all relevant information to show required pre-employment checks had been completed. This meant people were at risk of being supported by people who may not be of good character. At this assessment we found, all staff still had not received quarterly supervision in line with the provider’s policy and supervision documents were of poor quality. Some staff had, ‘an Ad Hoc supervision,’ this usually contained a piece of feedback, for example, 1 recorded only timekeeping, attendance and training and work being up to date . The providers policy stated, all staff would have quarterly supervision meetings to assess performance and competency. The failure to follow their own policy meant staff performance was not being assessed routinely therefore the provider was unable to establish if staff were working in accordance with their policies. At the last inspection we found there were insufficient staff to ensure a suitable programme of activities, this was still a concern. There was no activity coordinator in place or plan to ensure all people received meaningful activity. The provider advised they were in the process of attempting to recruit an activity coordinator. Following the assessment the provider sent us an example of an improved supervision template. They told us supervisions were now occurring regularly for staff.

We received feedback from 6 relatives. All 6 relatives told us their relative’s bedroom was kept clean and hygienic. However, some relatives felt bathrooms were not always clean and at times there was a strong malodour in the home when they visited.

Staff confirmed there was sufficient Personal Protective Equipment available and that they had received infection prevention and control training. Feedback from staff about the cleanliness of the environment was mixed. Most staff felt the home was clean with some expressing there had been improvements since the last inspection. For example, 1 staff member said, “In the past the home has smelt quite strong of urine, however, since the flooring has been replaced this has resolved this issue.”  However, concerns were raised by some staff that there were not sufficient cleaning staff available. Their concerns included, domestic staff being under pressure because there were only 2 of them, dining rooms and lounges not being cleaned during the day by cleaning staff with them being left to night-staff to do. Some of the night staff raised concerns about not having the time to complete cleaning tasks at night. One night staff member told us they were only able to clean the floors once people were in bed and it depended on what the difficulties were on the night shift as to whether these tasks could be completed.  We spoke with the manager about this, they told us they would review what tasks were allocated to the night staff. A member of the management team told us, “We do a daily walkaround and every Monday I get the cleaning schedules to review.” We observed this was not effective due to the concerns around infection prevention and control we noted during our assessment. The member of the management team also told us there was online training available and handwashing posters in toilets and that staff were good at using PPE and all knew how to put on and take off PPE.

Infection prevention and control was not managed safely placing people at risk of exposure to harmful bacteria and ill health. People’s food was not always in date or stored safely once opened, increasing the risk of contamination. Some equipment was unclean, the kitchen bin was over full, the lid did not close and there was debris on the main kitchen floor. The kitchen areas on each floor were unclean, in 1 kitchen area there was a missing plinth, with dirt underneath the cupboard. This was rectified by 18 April 2024. Unclean cutlery was kept in broken rusty drawers. In the fridge on the first-floor, ice cream was in a freezer compartment with a broken door, this was not temperature checked. When we conducted site visits on 18 and 19 April 2024, we found many of the same concerns. The environment was not clean placing people at risk from harmful bacteria and allergens, included walls on the ground floor and second floor dining areas were unclean. Sealant on a sink in a kitchenette was compromised. Kettles on 2 floors had significant built up limescale. The handwash dispenser in the second-floor kitchenette was covered in dust and a lamp in a bedroom was visibly unclean. On our fourth site we found the 2nd floor and 3rd floor kitchenettes were clean. The missing plinth had been replaced. Food was stored appropriately with expiry dates. Cutlery was clean and stored in clean utensil trays. The freezers within fridges did not contain any foods. We observed malodours in places throughout the on-site assessments, which were also observed by relatives and our on-site inspection team. While some attempts had been made to remove the malodour, this had not been successful. During our on-site visit on 23 April 2024, we observed 3 cleaning trolleys were visibly dirty. Following our visits, the provider sent photographs as evidence the trolleys had been cleaned. The provider also told us of action they have taken following our assessment to support the cleanliness of the home.

Systems and processes were not effective at picking up all of the concerns we found during our assessment. For example, we reviewed cleaning schedules for March and April 2024. We found 10 occasions where the cleaning rota had not been completed which meant we could not be assured cleaning always took place. On the dates the cleaning rota had been consistently ticked as being completed from our observations we were not assured all the cleaning duties on the rota were completed daily. For example, there was debris in 1 of the fridges, on the kitchen floor and under units. The legs and doors of some units were unclean. We reviewed a food temperature recording chart was in place and consistently filled out. The temperatures documented were within the correct limits. We found fridge and freezer temperatures were recorded twice daily. We reviewed the fridge freezer temperature recordings for February, March and April 2024. We noted on a couple of occasions the fridge was not operating within safe temperatures. There were several occasions the freezer was outside safe temperatures. We spoke to a member of the management team about the fridge and freezer temperatures being outside the correct limits on occasions. They told us the chef left on 15th March 2024 and said they did not have oversight of the fridge / freezer temperatures as the cook had been left to it. They told us moving forward they would ensure they had oversight of this. We reviewed the provider infection prevention and control policy. Following this review, we emailed the provider to ask if they had a named IPC lead at the home. if they had completed records, they could send us relating to the cleaning of equipment such as hoists and wheelchairs and if they had an IPC environmental risk assessment for each area within the home. The provider did not respond therefore we could not be assured these were in place. Following the assessment the provider told us they were taking action to improve monthly checks.

Feedback from relatives was mixed. Some relatives felt people received their medicines safely and on time. Other relatives had concerns with how medicines management was handled. Their concerns included finding tablets under a person’s chair and raising concerns with the provider about medicine management. One relative told us they believed the provider has changed the procedures for giving medicines and now used an App. We asked if relatives were informed if people became unwell and needed to see a GP, their responses were mixed with 3 relatives responding no and 4 relatives telling us they were kept informed about their loved one’s health.

Staff told us they did not feel online training was sufficient. A member of the management team told us staff could request additional training. Two staff confirmed they received a medicine’s competency check but were not sure how often. One staff member told us training was only repeated following mistakes being made. One of the staff members told us they were concerned about medicine stock control. They had raised this with the management team but felt their concerns were not addressed. Two staff were asked how risk associated with flammable creams was mitigated. The responses did not indicate staff understood the question, but 1 senior care worker told us, “Anyone prescribed flammable cream had information recorded and updated on their care plan. After administration creams are locked back in the medication trolley, they used to be left in the linen room.” We found creams were being stored inappropriately in store cupboards. The management team told us how they managed medicine concerns and provided examples of how this had been managed appropriately. Staff told us how they escalated concerns about medicines errors to a manager. The management team told us they ensured people received ‘as required’ (PRN) medicines safely by ensuring staff followed PRN medicines protocols. They said, “I know PRN protocols need work done on them.’’ They were able to confidently describe how to manage covert medicines safely and told us they had regular medicines reviews and talked about medicines during handover. They told us how they managed medicines errors, informing the relevant authorities, redoing medicines competencies, reflective supervisions and lessons learned. Staff told us the IT infrastructure created challenges in accessing electronic records, hindering administering medicines at times. Following the assessment the provider told us they were improving medicine monitoring including checking creams were stored correctly as part of their ongoing medicines audits.

Information was available to staff to support people to manage anxiety related behaviours, such as de-escalation techniques prior to the use of medicines. This was not always available at the point of administration. This meant staff did not have access to required information and may not have been administering PRN in line with people’s care plans. PRN protocols were accessible at the point of administration for most other PRN medicines. However, these did not always contain enough information to support staff in administering as prescribed. Medicines were not always administered in accordance with best practice. One person was prescribed medicine that had specific instructions of when to administer. This medicine was not always administered in this way. Another was living with Parkinson’s, requiring medicines to be administered at the same time each day. Sometimes administration was up to 3 hours after the prescribed time. Taking this medicine at the same time each day helps people get optimal control of their symptoms. Administering late could have negative effects on them. Risk assessments were not always in place for high-risk medicines. For example, for people prescribed medicines such as anti-coagulants, which increased the risk of bleeding, particularly if at a higher risk of falls. Medicines were not always stored safely and securely. We also found some medicines were out of date. Medicinal and non-medicinal topical creams were stored (adjacent to chemicals) in an unlocked store cupboard on 2 floors. The middle floor cupboard contained medicinal topical creams requiring refrigeration and were not temperature checked. Neither was locked despite being lockable cupboards, the ground floor cupboard was found unlocked again for a second time after we had informed the management team of our concerns. There were risks people could access these creams. After the assessment the provider told us of the action they were taking to make improvements.