Aria Court

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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 found a breach of the legal regulation in relation to safe and effective staffing and safe care and treatment. Some staff reported that when they raised safety concerns regarding people and staff that they were not listened to by some current and previous senior staff. People told us they felt safe, but we had concerns from observations and speaking to staff about the lack of staff, particularly at lunchtime which put people at risk. The service did not always have safe systems for appropriate and safe handling of medicines. We found that not all care plans contained sufficient information for staff to support people with their complex needs. Not all records were accurate or completed. Staff supported good infection and prevention control practices.

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 management team told us about the systems in place for staff and people to give feedback, how they investigate incidents and how they share learning points. Staff told us that they have supervision, monthly team meetings and daily handover meetings. However, one staff member told us that they had never attended a team meeting and had not regular supervision. A staff member told us carers don't voice opinions at meetings on one unit. A nurse told us that staff are 'sceptical to tell me something, think I might sabotage them'. Other staff said that when they have raised concerns in regards to staffing they do not feel listened to. A staff member told us that they didn't feel respected when they raised concerns and it made them hesitant to speak up. The management team acknowledged that staff had felt unsettled and they want to build relationships with staff. One staff member gave several examples of raising serious concerns about people with senior staff and not being taken seriously. A new manager had been in place for 2 weeks when we visited the home and staff spoke positively about their impact on the home.

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 were happy that their family members were safe, staff were pleasant and any medicine changes were communicated. People told us 'they are quick to pick up on chest infections and get the doctor in’. One relative told us when they raised a concern about a member of staff that senior staff spoke to them, however they were not aware of the outcome of the discussion.

Staff told us they had safeguarding training and knew how to report concerns. The management team talked through the systems in place to follow up on concerns and gave examples of lessons learnt. They said they ensure that staff understand safeguarding procedures by discussing them as part of staff induction, in staff meetings, during supervisions, through training and sharing lessons learnt on a daily basis. The manager said she wants to build trusting relationships with staff. Some staff told us that they don't always feel listened to and gave examples of raising concerns about the safety of staff and people and not being taken seriously by the management team.

We observed staff did not always take action to mitigate identified risks. For example, we observed someone lying down sleeping with their head only slightly raised and their food tray on their lap. This could have been a choking risk if they woke up and no staff were present. Safeguarding posters were seen around the home.

We found that senior staff did not always identify allegations of abuse or make referrals in line with policy. Appropriate Mental Capacity and Best Interest Assessments are in place. However, we did not feel that there was enough information in care plans to support people who may display behaviours that challenge and guidance for staff on actions to take. Safeguarding topics and lessons learnt are discussed in supervisions and team meetings. A safeguarding policy was in place and records showed that staff had received safeguarding training. Sexuality and sexual needs are considered in the care plans. Care plans contain information on any restrictions in place and Deprivation of Liberty Safeguards care plans detail any conditions.

One relative told us that their family member was 'unable to pull a chord for help but would make sure they were being listened to' and they felt that they 'wouldn’t get a better response, although it might not be immediately'. One relative told us that they were informed immediately when there was an incident regarding their family member and said that they '100% believe that staff would call the right people when needed.' Another relative of a family member told us that staff 'are quick to pick up on chest infections and get the doctor in. If tablets get changed we’re told about it’. Another relative told us that 'they are responsive to illness, I’m told about any medicine changes’. However, one relative raised concerns in how staff support their family member who may refuse support.

Staff were aware of when they might need to act in someone's best interests, and talked about positive ways to support someone with behaviours that challenge. This included treating everyone as an individual, being calm and relaxed and providing reassurance. Staff knew the process to follow if there was an incident and said that 'most of the time call bells do get answered and in an emergency'. However, they also said that it 'might be a struggle to get there immediately.' One staff member said there is 'not a clear process following an incident' and felt that care plans did not reflect people's needs and some people were not on the right unit to safely support them.

We saw positive interactions between people and staff. We saw staff supporting people safely to reposition and identifying risks including suggesting someone move out of the sun to the shade and encouraging drinks. However, we saw that not all staff were responsive or able to reassure people who were distressed.

Care plans included people’s preferences and choices. However, some care plans lacked evidence of involvement from the person and lacked information. In the section of the care plans regarding how someone communicates their preferences, choices, what is important and how they spend their day there were just yes or no answers. Some care plans referred to family members making decisions and signing documentation who did not have the legal authority. People had Deprivation of Liberty Safeguard care plans in place which detailed any conditions and the renewal date. We did not always see completed tools to assess people who were unable to communicate when they were in pain. Support plans and risk assessments did not always contain enough information about how staff should support people who were exhibiting distressed behaviour. When someone had bed rails in place there was a care plan and risk assessment completed and it referred to advance decisions, power of attorney, best interest decisions. However, these were not always updated every 12 months. Staff complete Mental Capacity Act and Deprivation of Liberty Safeguards training.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives in general did not have concerns in relation to staffing levels or staff competence. One relative told us that their family member 'won’t use the call bell but is checked regularly’. Another relative told us that their family member 'needs to be moved every two hours, I know that’s done. They won’t hoist unless two carers are here. The staff are great.' However one relative told us that there are ‘not enough staff'. They said 'staff don't have any time to themselves, as a team they would benefit from more staff, such an unpredictable job. No time to sit with people and give them time.’ Some people and their relatives raised concerns around delays to meet their needs. One relative said they weren't sure if prescribed exercises were being completed for their family member and another said there can be delays in staff administering 'as required' pain medication. One relative said they had issues in regards to provisioning of an appropriate diet for their family member and another raised concerns about communication from staff.

Staff told us that 'people can have to wait hours for their personal care and if you rush you do mess up, creams get missed, don't have time to fill in shower chart or cream chart, you forget.’ Staff told us that ‘meals is the thing that puts the pressure on us’, ‘not enough to get round them all, wait ages to get food’. One staff member raised concerns about the skills and experience of one member of staff that had not been addressed. They told us how they had raised concerns about people’s needs not being met to senior staff but were ‘ignored’ and not respected. A member of the activities team told us 'if they are short at lunchtime I will give them a hand, answer a bell.' They said 'some days only 3 and need 6 on unit, be good to have more personal time.' However, the management team told us that staffing levels are based on their dependency tool. They told us staffing ratios are good at the moment with more regular staff and much less agency staff. The Manager told us about how they are addressing concerns and performance managing staff when concerns have been raised. The Manager confirmed that the service is not effected by weekends when unit leaders are still present, there are the same staff ratios, still reception staff and activities.

During the visit we observed that there were not enough staff to support people with their meals. We saw people sat on their own who needed support to eat their lunch. We also observed people calling out and staff not responding. On one unit we saw a member of staff was not communicating with someone effectively to reduce their upset. However, Senior staff were observed to be responsive and have the skills to reassure people who were distressed.

The home uses a dependency tool to calculate safe levels of staffing. We found that this was not accurate in reflecting the needs of people who require support with eating and drinking. The rotas showed that there were days when the recommended number of carers, nurses and team leaders were not in place. Recruitment checks, including criminal records checks had been carried out to ensure only suitable staff were employed.

People told us ‘the home is always clean and tidy, the room is cleaned daily and they do a deep clean monthly’. Visits are enabled without restriction and people have a choice of whether they would like a bath or shower.

When staff were asked about infection prevention control they said that most of the time the home is clean. They said it is always cleaned and that if areas get dirty that 'normally at end of shift staff tidy up'. Staff said there was always personal protective equipment (PPE) available and that 'cleaning systems work well'. They said that outbreaks are managed well and kept contained with infection posters to put on doors so people don't access infected areas.

During the visit we saw that the home was very clean, staff were wearing appropriate PPE and seen changing it when required. Staff were observed washing their hands and hand washing guidance is on display. Housekeeping staff were seen during the visit and the chemical store and sluice room were kept locked. There were no bins overflowing and bathrooms were clean and well stocked. Colour coded cleaning systems were seen for cleaning materials and equipment and for safe laundry and waste management. Staff were observed keeping areas clean and demonstrating safe food hygiene practices. Equipment was observed to be well maintained and clean. However, we observed that there was a commode in one room without a lid or cover.

The PPE policy is reviewed annually and provides detailed guidance clearly stating the risks, procedures and what to wear when. From the observations at the site visit there were no concerns that staff were not following protocols. Evidence was seen of group supervisions regarding the importance of staff hygiene. Any infections people have are monitored and discussed in clinical meetings. There is evidence that concerns are shared with other agencies when required. Staff complete infection prevention control training every two years. However, infection prevention and control audits were not always fully completed and when areas for improvement were identified actions were not always recorded.

Staff interacted with people kindly and provided support to people when medicines were administered. Staff carried out additional monitoring for medicines where necessary to ensure that they were safe and effective. However, not all care plans contained sufficient information for staff to support people with their complex needs. Person centred guidance was not always in place to support people to have their ‘when required’ medicines and outcomes from this were not always assessed and recorded to ensure they were effective. There were no tools available at the home to assess people who were unable to communicate when they were in pain. This meant that there was a risk people would not receive appropriate treatment if they were in pain. During the visit we saw staff administering medicines to people in a kind and caring way and were able to answer questions from people about their medicines. People were given their medicines including time sensitive medicines at the right time to ensure that they were effective. Medicines including controlled drugs were stored securely. However, we saw some expired medicines, one of which had been administered to a person. We escalated this immediately and this was disposed of appropriately.

Staff worked with healthcare professionals to review medicines and escalated concerns appropriately. There were processes in place to ensure medicines were ordered in time. Staff received medicines training and were regularly assessed as competent. Medicines related incidents were reported and investigated. Staff told us that lessons learned were cascaded through meetings.

Best interests’ decision meetings had taken place for people who had had their medicines administered covertly (disguised in food or drink). Advice from pharmacists was in place to ensure that medicines were administered safely. People with topical medicated patches had records in place to ensure that these were rotated in line with manufacturers recommendations. People’s allergies were accurately recorded. However, staff did not always document when topical creams had been applied. Therefore the service could not be assured that this had been carried out according to prescribers instructions. A medicines policy was in place, but we saw that staff had not followed this as we found an expired medicine had been given on three occasions to a person in the previous month.