Aran Court Care Home

Accidents and incidents involving service users were not consistently investigated and action taken to keep people safe, in a timely manner. The provider had failed to ensure their own accident and incident policy was consistently followed. This meant opportunities to learn from these events and reduce the risks to people were lost. People’s rights under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) were not fully understood by staff which meant people were at risk of being subject to restrictions which were not proportionate or in their best interests. This was a breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that despite staff being aware of the risks to people, what they told us about risks to people was not consistently recorded in people’s care plans and, in some cases, risk assessments were also missing. People’s risk assessments were generic, and not person-centred. This meant staff were not consistently provided with the most up to date, detailed information on how to support people safely and effectively. People told us they felt safe and that there were enough staff to support them and respond to their needs. People were supported to take their medicines safely. Although the people we spoke with expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards. The provider took on board all feedback given during the assessment process and were in the process of producing action plans to address the concerns raised.

Systems were in place to gather information regarding people’s health and care needs, but care plans and risk assessments did not consistently assess all known needs for people. Staff worked alongside a variety of healthcare professionals to ensure people had access to these services. However, some care records did not hold person-centred information regarding people’s particular healthcare needs which could prevent staff from supporting people safely and effectively. Actions were being taken to review the information held in people’s care records in order to address these concerns. Improvements had recently been made in the quality of food that was provided after people raised concerns. Concerns were raised regarding the information available to staff about people’s dietary needs and immediate actions were taken during the assessment to address these concerns. The provider did not have effective oversight of DoLS which had the potential for unnecessary restrictions being placed on people.

The provider’s complaints system was not effective and they had failed to follow their own complaints process. The provider had failed to maintain a record of all complaints received, the outcomes of these and actions taken in response to complaints. There was no analysis of complaints over time which would identify any potential trends and areas of risk that would need to be addressed. This was a breach of Regulation 16 (Receiving and acting on complaints) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although most people told us they had some involvement in the development of their care plans and told us staff knew them well, care records seen lacked person-centred detail regarding people’s likes, dislikes and their life history. Work was planned to address this but, at the time of the assessment, a cohesive plan was not in place to co-ordinate this piece of work.

We found the provider had failed to operate effective governance systems to enable them to assess, monitor and improve the quality of care for service users. There was a lack of effective analysis of accidents and incidents and complaints, which would identify any potential trends and areas for action to ensure the safety of people living at the service. The provider’s policies and procedures were not being consistently followed when responding to complaints, accidents and incidents and DoLS which meant the provider did not have effective and robust oversight of the service. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The arrival of a new management team at the service was positively welcomed by people, relatives and staff alike. However, it was of concern that 2 members of the management team left the service during the assessment process. We were advised actions were being taken to recruit into those positions as soon as possible. Staff reported morale had improved and they were being given the opportunity to raise any concerns they may have and have their voice heard. Staff continued to work well with other healthcare professionals in order to meet people’s healthcare needs. Both staff and people’s views of the service were being sought to obtain feedback on the service in order to drive improvement. The management team took on board the feedback provided during the assessment process and committed to putting actions in place to address the concerns raised.