Richmond Village Aston On Trent 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

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 requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm. During this assessment, we found the service remained in breach of legal regulation in relation to safe care and treatment.

This service scored 53 (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. They investigated and reported safety events. However, lessons were not always learnt to continually identify and embed good practice. Areas identified during this assessment were not always identified and action was not previously taken to improve. For example, records used to monitor when people displayed agitation, or distress did not contain sufficient detail of de-escalation techniques used to support the person. However, people and their relatives told us they felt able to raise concerns and these would be acted upon. Leaders reviewed incidents and accidents for patterns and themes.

The service 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. Staff told us they were provided with adequate information on how to care and support people when they are newly admitted to the service. The registered manager told us, “We work to ensure that transitions are as seamless as possible for people, and that they are safe. When we are considering a new resident, we ensure a robust and detailed assessment takes place prior to their admission”.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People we spoke with told us they felt safe at the service. Leaders and staff showed a good understanding of safeguarding, and we found the service shared concerns appropriately.

The service did not ensure risks to people were mitigated to prevent the risk of deterioration of people’s health and well-being. They did not always ensure staff were consistently delivering support to people in line with their care plans. For example, records kept by staff did not always evidence people received effective support with pressure relief in line with their care plans. We found where people experienced distress or agitation, their care records did not capture personalised information on how best to support the person. This included a lack of detail on how best to support the person through the period of distress or agitation.

The service did not always detect and control potential risks in the care environment. For example, we found areas of the home which were not always secure, resulting in areas which were accessible to people and presented a potential risk to their health and safety risk. However, we found the service was presentable with fresh décor throughout.

The service had appropriate staffing levels and to make sure people received consistently safe, good quality care that met their needs. Staff had received training which was appropriate and relevant to their role, including in specialist areas such as, catheter care. Staff were supported to deliver safe care, including regular supervisions and competency checks.

The service did not always assess or manage the risk of infection. They did not always have appropriate control measures in place to prevent the risks of infection. We found areas of risks during the assessment which had not been identified or acted upon. For example, poor pressure cushion hygiene, waste disposal not always being managed in line with national guidelines and personal protective equipment (PPE) not always being readily available at designated PPE stations. The provider took action to address these shortfalls following this assessment.

The service had not always made sure key updates were made to people’s medicine care records when there had been a change of need. For example, where people were no longer receiving a medicine as ‘when required’, their care plan were not always updated to reflect this change. Protocols for ‘when required’ medicines did not always capture sufficient detail and guidance to support staff on when to administer the medicines. For example, 1 person was prescribed a medicine to be administered to support their agitation. The protocol did not contain detail of when to administer this medicine to the person such as, if other de-escalation techniques had been unsuccessful. However, we found areas of improvements at the service in relation to medicines following their last inspection. The provider had implemented proactive governance systems in this area to minimise the risk of medicine errors, which had been effective.