Ardent Residential Care 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

This key question has been rated inadequate. We found breaches of regulations in relation to safe care and treatment, safe effective staffing, safe environments and infection prevention and control. The provider lacked effective systems to ensure lessons were learnt and outcomes used to promote sustained improvement. People were not protected from the risk of harm as their care needs had not been robustly assessed and mitigation was not always in place to manage risk. Systems and processes were not in place to ensure people were safe from risks associated with the environment they lived in. The service was not clean or hygienic and had unpleasant odours throughout. People were not cared for by enough staff or staff that had the skills and knowledge required to care for them safely. We found there were areas requiring improvement in relation to the management of medicines stock.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People continued to be at risk as action had not been taken to learn from concerns raised at previous inspections. The provider had failed to develop and cultivate a learning culture at the service. People and relatives did not know who was in charge or who to go to if they had concerns. One relative told us, “I wouldn’t say there is any real leadership. The staff seem to just do their own thing.” Another relative said, “We wouldn’t know who to speak to other than the staff we see when we visit. There doesn’t seem to be a hierarchy of authority.”

Staff were able to tell us about the process for reporting accidents and incidents. However, we found there was no formal process in place for staff to reflect on accidents and incidents and there was a lack of understanding of the importance of analysing accidents and incidents to help reduce the risk of them happening again.

The provider lacked effective systems to ensure lessons were learnt and outcomes were used to promote sustained improvement. We found people’s safety was impacted due to on-going significant shortfalls with the safety of the environment we identified at the last assessment. Systems were either not in place or effective in ensuring improvements or good practice was being embedded. The provider did not have a robust system in place to review accidents and incidents to ensure that appropriate action had been taken and any patterns, themes and trends were identified to ensure lessons were learned and shared with staff. Accidents and incidents were being recorded and appropriate action had been taken in some instances. However, care plans and risk assessments had not been updated following incidents. This placed people at risk of avoidable harm. For example, one person had an unwitnessed fall which resulted in an injury to their arm. Their care plan had not been updated with guidance from their medical team to keep the person’s arm in a sling and have daily physio exercises. During the inspection we saw this guidance was not being followed by staff and the person did not have their sling in place.

People did not experience a safe transition into the service. People who had been admitted to the service had not had all of their risks assessed or care plans created to mitigate risks. Relatives we spoke with told us they were not involved in their relative’s admission or involved in any assessment of their care needs or care planning, where appropriate. People’s relatives told us people were not always supported to attend healthcare appointments when needed due to the lack of staff available.

The trainee deputy manager was not clear about safe systems needed to admit new people into the service. Staff did not complete their own pre-assessment of people’s needs and relied on information provided to them from other health professionals. Staff told us they read people’s care plans and spoke with people to understand how to meet people’s needs. However, we found care records did not include important information and guidance from pre- assessments completed by other health professionals prior to people being admitted to the service. Care plans did not always contain accurate or sufficiently detailed information about people’s care needs or risks.

We did not receive any concerns from visiting health professionals prior to our assessment. Following the assessment health professionals told us staff and the management were working with them to make improvements.

Robust processes were not in place to ensure a safe and smooth transition between services and to reduce risk of harm to people. Effective assessment arrangements were not in place. Care records throughout lacked sufficiently detailed information and guidance for staff to ensure people received the health support they needed, and that preventative healthcare was accessed.

People gave us mixed feedback about how safe they felt living at the service. Whilst some people told us they felt safe and staff were ‘Fantastic,’ others expressed concerns. For example, people told us about incidents where they felt unsafe due to the lack of staff supervision. One person told us, “I find it distressing in the dining room and the lounge when some of the men are in my face. I don’t want to be here and the other day I packed my bags because I wanted to leave.” Another person told us, “I don’t like it when the man wanders into my room.” Most relatives felt their family member was safe and commented positively about staff. However, one relative felt the stairs posed a risk to their relative and another felt their family member needed more supervision.

Staff told us what they would do if they suspected that people were being abused. However, due to the lack of sufficient information and guidance in place for staff to follow we were not fully assured staff would recognise deterioration, which could mean people’s needs not being met and possible neglect.

We observed staff were respectful towards people and people looked comfortable in staffs’ presence.

Policies and procedures were in place to protect people from the risk of abuse and neglect. However, we were not assured that managers or staff understood their responsibilities in relation to keeping people safe from harm and neglect. Staff and managers had failed to identify the concerns and risks we had found during our inspection. People were placed at risk of harm through areas of poor practice and lack of robust management and provider oversight of the service.

People were not protected from the risk of harm as their care needs had not been robustly assessed and mitigation was not always in place to manage risk. For example, one person’s hospital discharge form stated they were a high risk of falls, they often walked around at night. They recommended the service supervise the person when walking around and consider using a sensor alarm mat for their safety. We found this person had been placed in a bedroom at the top of the service and had unsupervised access to 3 flights of stairs. There was no sensor alarm in place. The lack of robust risk assessment and management put this person at risk of avoidable harm. We immediately brought this to the attention of the trainee deputy manager and asked them to take immediate action. Concerns were also raised by this person’s family. They said, “Nobody can see her up there. We are concerned about the stairs she can access with no supervision.” People and their relatives, where appropriate, told us they were not involved in care planning and assessing people’s individual risks.

We were not assured that the trainee deputy manager and provider had a clear understanding of risk. For example, we discussed the incident we refer to above with the deputy manager, they had not identified the risk and did not appear to understand the risk or have a solution as to how to mitigate the risk for that person. Whilst staff were able to tell us about people’s care needs, we were not assured staff had sufficient information about people to manage risks.

During the inspection we observed instances where people were not supported in a way that ensured their safety. Staff did not always follow peoples risk assessments and care plans. For example, we observed one person was not being supported to move around the service in a safe way and was at risk of falling. Another person was not supported to eat their meal according to their assessed need.

People were placed at increased risk of harm as systems and processes were either not in place or robust enough to ensure risks were appropriately managed and mitigated. Risk assessments and care plans were not always in place and lacked sufficient guidance for staff on how to manage and mitigate risk. Risks associated with people’s skin, risk of falling and risk of choking were not always identified, mitigated or managed. Processes in place to monitor people for their safety were not robust and there was a lack of consistent managerial oversight to ensure people’s needs were being met. Care plan reviews were not always being completed regularly or when people’s needs changed. The concerns detailed above contribute to the breach of regulations in relation to safe care and treatment.

People were not living in an environment that was safe. Although people generally did not express any concerns with the safety of the environment, some relatives commented they had concerns, and the service was run down. For example, relatives’ comments included concerns the ground floor toilet was extremely small and not fit for purpose, there were stains on walls throughout the service, radiators were noisy, the service was cold at times and taps did not always turn off.

The provider, trainee deputy manager and staff had not identified the concerns we found with the safety of the environment. Staff told us there had not been a cleaner at the service for over 2 weeks and the service had been without a cook for a week. Staff told us they were having to clean the service and cook people’s food alongside supporting people with their care needs. The trainee deputy manager told us they were currently recruiting for a cleaner and cook but until these were in post, care staff were allocated to clean and cook at the service.

The environment was not safe. We observed 3 windows did not have window restrictors fitted. 2 windows were at the top of the building, 1 opened out onto the roof and another to the side of the building. Multiple windows did not have Health and Safety Executive compliant tamper proof window restrictors fitted. This put people at risk of falling from a height. People were at risk from unsafe fire safety practice. We observed multiple fire doors wedged open with paper and card. We observed some radiators did not have radiator covers and numerous radiators with covers, were not secured to the wall and could be moved and removed. We saw a door to the boiler was open. This put people at risk of burn injuries. We observed a cupboard containing toiletry items and hazardous chemicals had been left open and the lock was broken. Another unlocked cupboard contained painting pots and a saw. This put people at risk of injury. Throughout the service, including in people’s bedrooms, trailing electrical wires, leads and cables put people at risk of falling and tripping. We observed an aerial socket was broken exposing wiring and an electrical isolator switch socket was hanging out of the wall. These observations put people living at the service at risk of harm and contributed to a breach of regulations in relation to safety of the environment.

At the last assessment in February 2024, we identified concerns with the safety of the environment. We issued a warning notice to the provider asking them to make immediate improvements. At this inspection we found sufficient improvement had not been made and the service had deteriorated further. The providers systems and processes in place to ensure the safety of the environment were inadequate. Management and provider oversight had failed to identify the significant safety concerns at the service. Systems and processes were not in place to ensure people were safe from risks associated with the environment they lived in. There were no monthly environment audits in place to regularly check the safety of the environment. Audits that were in place such as window audits and infection prevention and control audits, had not identified the serious concerns that we identified. The lack of robust systems and processes put people living at the service at risk of harm and contributed to a breach of regulations in relation to safety of the environment.

We received mixed feedback from people about staffing levels, with some people saying they thought there were enough staff. However, family members did not think there was enough staff to care for people well. Comments included, “No I don’t feel there are enough staff. He has some hospital appointments that they don’t have enough staff to accompany him to the hospital”, “I do find that I have to look for people if I need someone” and “No. There’s not enough staff and to be honest I’ve never seen so many as I have today in the 6 weeks he’s been here.”

Most staff felt there were enough staff and they worked well together as a team. However, some staff felt staffing levels had been better, and there needed to be more management support. Whilst staff reported receiving an induction and face to face training, we were not assured that training provided was of good enough quality to equip staff with the skills to support people effectively and safely. This contributed to the breach of regulations in relation to providing safe and effective staffing.

During our site visits, whilst we observed a staff presence in communal areas, we noted there were limited staff checks on people in their rooms. This placed people's health, safety and wellbeing at risk. We also observed care staff were having to complete cooking and cleaning duties alongside meeting people’s care and support needs. This impacted on the care and amount of time staff could give people. We did however, observe lots of kind and caring interactions from staff, and that staff were trying hard to meet people’s needs in a timely way.

We were not assured people were cared for by staff with the skills and knowledge required to care for them safely. Processes were in place to monitor staff training using a training matrix which identified staff had received training in a variety of subjects. However, we found the providers training matrix and certificates issued to staff showed staff had completed 18 courses on the same day. These courses included practical manual handling training, practical first aid training, Health & Safety risks and hazards, safeguarding vulnerable adults, the 5 principles of Mental Capacity and Deprivation of Liberty Safeguards, food hygiene and infection prevention and control training. We were not assured staff training at the service was of an adequate standard and length or comprehensive enough to equip staff with the knowledge and skills required to care for people safely. At the time of the assessment there were not enough staff employed to meet people’s needs safely. The service did not have a cleaner or cook employed, and the provider had not made any temporary arrangements, such as agency staff, whilst recruiting. This meant care staff were having to clean and cook alongside providing care to people. Not ensuring there were sufficient numbers of staff and failing to ensure staff were supported with effective training contributed to the breach of regulations in relation to providing safe effective staffing. Recruitment processes were in place which included ensuring staff had the right to work in this country, had appropriate references, and disclosure and barring checks had been completed.

Whilst people we spoke with felt happy with the cleanliness of their rooms, relatives felt aspects of the service were not clean and there were unpleasant smells. One relative told us, “There is always an odour when you walk in the door. I think they only have one cleaner. There were marks on the wall in his room when he moved in and they are still there a month later.” Another relative commented, “I think it’s awful. On the first day we had to clean her bathroom. The toilet is brown in the bottom, it’s disgusting.” The concerns detailed above contribute to the breach of regulations in relation to safety of the premises.

The provider, trainee deputy manager and staff had not identified the concerns we found with infection prevention and control. Staff expressed concerns that due to the lack of domestic and kitchen staff they were having to clean and cook alongside their caring duties. Staff told us they had not been specifically trained to undertake these roles.

The service was not clean or hygienic and had unpleasant odours throughout. We observed communal bathrooms and toilets were not clean or hygienic and used toilet paper was strewn across the floor in 2 rooms. We observed equipment in people’s rooms, such as, a person’s chair and alarm mat, had dark brown stains on them. Used personal protective equipment was not disposed of correctly and had been left out on top of the yellow clinical waste bin. Yellow clinical waste bins were dirty and stained. We observed kitchen work surfaces and shelves, cooking equipment and food preparation equipment was dirty and covered in stains and grease. The kitchen floor was dirty with stains and food debris. Coloured food chopping boards used to prepare foods and prevent cross contamination were not stored in line with infection control guidelines. Following this observation we contacted the Foods Standards agency.

Systems and processes in place, such as, infection prevention and control audits and oversight by managers and the provider had failed to identify the serious concerns we had with infection prevention and control at the service. Whilst there were cleaning checklists in place these were not robust and there was a lack of oversight by managers of cleaning at the service. The concerns detailed above contribute to the breach of regulations in relation to safety of the premises.

People’s medicines were not always managed well. Whilst most people and their relatives told us they received their medicines when they needed them, one person and their relative told us staff did not give them their medicines when they needed them and as prescribed for them. The person said, “I’ve had to keep asking about not receiving the paracetamol I take which I need as I’m in a lot of pain.” This meant the person was unnecessarily in pain which could have been avoided by staff managing their medicines correctly.

Staff knew how people liked to take their medicines and when they needed to seek advice from health professionals if people declined their medicines. We spoke with the trainee deputy manager about the issues we found with medicines stock processes. They confirmed that there was no process in place to make sure that medicines stock tallied with medicines administered. They told us they would ensure processes to do so would be implemented.

Processes were in place to support the management of medicines. However, we found there were areas requiring improvement in relation to the management of medicines stock. Whilst there was a process in place to count how many tablets were in stock, there was no process in place to check the stock was correct and tallied with the amount administered as recorded in people’s medicines administration records (MAR). For example, one person’s MAR chart for their memantine medicine showed there should be 20 tablets left in stock. Actual stock amount counted with staff showed there were 23 tablets left. This could indicate staff were recording medicines had been administered when they had not. In addition to this, it appeared medicines were not always being checked in once received and stock balances adjusted. For example, one person’s MAR chart stated 134 tablets of their medicine had been received. Their MAR record showed 150 tablets had been administered. However, there were 98 tablets still in stock. This indicated additional stock had been received but not recorded. Not having a robust system in place meant the provider could not be assured people were receiving their medicines as prescribed for them. These concerns have contributed to the breach of regulation in respect of safe care and treatment. Medicines were being stored appropriately. Room and fridge temperatures were being checked daily.