Ackroyd 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 inspection we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For instance, the provider had systems in place to record and analyse accidents and incidents. Action had been taken to mitigate future risks such as liaison with specialist professionals.  One relative told us, “The staff are very good; I can talk to them about anything. I trust them to be honest with me.”

The service worked well 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. Relatives told us about their experience of their family member moving into the home. One relative said, “[My loved one] has been there a few months. They couldn’t do enough to get them settled in. [My loved one] was very frail when first admitted and was on end of life care. They are looking more confident now since settling in. They are also happy when I go home now; that shows how settled they are. When they moved in, we had an information thing to fill in. Things like [my loved one’s] likes and dislikes and what they like to eat; What their interests are, and the staff observe them.” Another relative said, “The move into the home was very easy. [My loved one] had an assessment initially. [Staff] know what [My loved one] likes and doesn’t like.” People said staff supported them to access health care services. One person said, “I see the doctor if I have a problem. I’ve had my flu and Covid vaccinations and my vitamin B12 injection.” A relative told us about healthcare services their family member had access to. They said, “[My loved one] sees a doctor when needed. I’ve seen the doctor visit. The staff are very attentive. [My loved one] is down for a dental appointment soon.”

Staff worked with people and healthcare partners to understand what being safe meant to people and the best way to achieve that. Staff were trained in how to identify signs of possible abuse and the action they should take if needed and the service shared concerns quickly and appropriately. We found people were protected from bullying, harassment, abuse, discrimination, avoidable harm and neglect. There were no restrictions in place to prevent people from having visitors. Everyone said they felt safe with the staff. For instance, a person told us, “It’s a nice place to be. The staff are very kind; we get on very well.” A relative said, “[My loved one] is safe. The staff have always got a smile on their faces. They’re happy to see us.” The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

The service provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments and care plans covered all aspects of people’s health as well as their daily living activities. Theses identified situations where people may be at risk and helped people and staff to minimise those risks. People and those close to them felt risks were well managed, without overly restricting people’s freedom. One relative said, “Yes, the home is safe. [My loved one] has had accidents due to frailty. They have set up the monitors now in case [my loved one] gets out of bed. They did deal with it quickly. The manager was very good at finding out what happened.”

We found the service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks and maintenance were carried out to make sure the environment was safe. Regular meeting were also held to discuss potential risks and how they could be managed. Maintenance records were up to date and any actions addressed. Everyone said the environment was well maintained. One relative said, “[My loved one] has a good sized room. They have their pictures up in their room. Staff put [my loved one’s] pictures up straight away when they arrived. It’s always clean. It’s nice and warm and well maintained. [My loved one] has a buzzer and a mat with a sensor in their room. They need to use the hoist. All of this equipment works well. The staff are very responsive to [my loved one’s] needs.”

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. No-one raised concerns with us about the staffing of the service and we received positive feedback about the staff. One person told us the staff were nice, and well trained. One relative said, “The staff are really good, and the way they look after [my loved one], they tick every box. They don’t have a quick turn over of staff.” Another relative told us, “The staff are all lovely, and incredibly helpful.” Staff were recruited safely. The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly. The home was clean, and the team undertook regular infection prevention and control (IPC) audits to make sure staff were working within IPC good practice guidance. People told us there was a high standard of cleanliness and infection prevention and control. One person said, “I’m now in a lovely room. I have things in there from home. I have pictures on the wall; it’s like a room from home. They clean it everyday. I change my clothes and they go to the laundry to be washed. They do a good job. My clothes come back nice and clean.” One relative said, “The home is clean. The staff wash their hands and they wear gloves and a disposable pinny. We never have problems with the laundry it’s perfect.” Another relative said, “It’s very clean and tidy. The home doesn’t smell. I’ve not seen anything that’s not looked after.”

We found the provider made sure people’s medicines were ordered, administered, stored and disposed of safely and people were supported to take their medicines in the way they preferred. Staff administering medicines had received the appropriate training and had been assessed as competent to administer medicines safely. People and relatives were happy with the support provided to people with their medicines. One relative said, [My loved one’s] medication is all monitored and dispensed correctly. [My loved one] sometimes refuses to take it so they will try to give it again later.” Another relative told us, “They make sure that [my loved one] takes their medication. A doctor has been to see [my loved one] every now and again. [My loved one] has a lot of medical needs and the home cope with this very well.”