Archived: Asquith Hall

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 look for evidence that people were protected from abuse and avoidable harm. At our last inspection this key question was rated requires improvement. At this assessment, the rating has now changed to inadequate. Effective systems were not in place to assess, monitor and mitigate risks to people and keep them safe. People were placed at risk of significant harm and/or injury due to this. People were not protected from the risk of infection, as prevention and control measures were not implemented consistently. The environment was not always safe and standards of cleanliness and hygiene in areas of the home were poor with some rooms being unfit for human habitation. Equipment used for providing care to people was not always used in a safe way. Fire safety risks were not assessed and managed safely. People were exposed to the risk of harm due to medicines not being managed safely and there were insufficient quantities of medicines available to meet people’s needs. People were not safeguarded from the risk of abuse. There were not enough suitably qualified, competent and experienced staff to meet people’s needs and keep them safe. We identified 5 breaches of regulation in relation to, person-centred care, safe care and treatment, premises and equipment, staffing and good governance.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experience living at the service was not considered by the provider. They did not involve people in their care or management of risks and their views were not obtained and acted upon. People’s risks were not accurately assessed and managed which reflected a culture whereby people’s safety was not prioritised, and lessons were not learned, shared appropriately or used to make improvements. One person told us, “This is a horrible place. I think it's called a care home but there's no caring. I have to look after myself, no support with a wash or shower. I would love to live anywhere else, anywhere at all.”

Staff did not know how to keep people safe. They told us they were not supported in their learning and had not been trained in basic practices to enable them to support people safely, for example, moving and handling. Staff told us they had not completed an induction and were not provided with the information they needed to support people safely and meet their needs.

Systems and processes in place to report, monitor and learn from incidents were inadequate, placing people at risk of ongoing harm. There was no evidence of action being taken as a result of incidents to mitigate risks to people and prevent reoccurrence. Incidents were not being appropriately reported, analysed and used to improve practice. Staff had not received training for accessing the electronic record system which meant incidents were not always accurately recorded and reported. The manager told us there was a backlog of accidents, incidents and safeguarding that needed reporting. Lessons were not learned and shared to mitigate risks to people.

People did not experience safe systems of care whereby their health needs were responded to safely, efficiently and effectively. Where people needed input from other health care professionals, for example, the community mental health team, referrals had not been completed. People’s health had often deteriorated significantly before other health care services were contacted. One person told us they always miss their appointments, for example, the opticians.

Staff and leaders did not always identify and respond to people’s deteriorating health needs. There was often no action taken or significant delays in people accessing health professionals. One staff member told us that people had been admitted to the service and no referrals to the GP had taken place. They also told us 1 person experienced a delay in receiving medical attention, as staff on the day shift had not noticed the person’s symptoms and deteriorating health. In addition, staff expressed concerns about their ability to prepare for new admissions robustly and safely, For example, 1 person had been admitted to the service but the staff member on duty had not been made aware of this, therefore the person did not have any of the equipment in place that they needed.

Partners and health professionals working with the service identified that partnership working was not effective, people’s health needs were not being met and professional advice was not being followed when staff were caring for people. For example, 1 professional told us they had significant concerns that people’s wound dressings were not being changed and that staff were not responding to people’s deteriorating health. We observed instances during inspection whereby external health professionals had visited 1 person and during their visit noticed a deterioration in another person and had to respond to this because staff at the service had not safely monitored the person and identified the need for action.

Systems and processes to ensure safe systems of care, continuity of care and partnership working were inadequate. Processes in place were not effective in ensuring people were safely assessed and monitored. Referral processes were inadequate and there was a failure to implement professional advice and respond effectively to people’s deteriorating health needs, placing them at significant risk of harm.

People were not safe and were not protected from abuse and avoidable harm. One person told us they felt scared. They told us a resident had punched them in the face very hard and when they informed staff they were told they had to put up with it.

Staff and leaders did not demonstrate their responsibilities to keep people safe. They did not always record and report safeguarding concerns. Where concerns of a safeguarding nature were raised action was not always taken. A staff member told us, “Nobody takes action. I don’t feel comfortable sending my safeguarding reports to [management]. They change them or don’t send them.” The manager told us there was a backlog of safeguarding concerns that needed completing.

We observed neglectful practice and a failure to protect people from harm. For example, we observed a staff member underneath a person’s bed, fixing it whilst it was raised into the air, with the person still in the bed. The person was a known falls risk. When this was raised with the staff members and a manager there was a lack regard for the risk posed to the person.

The culture at the service was neglectful. Risk management was inadequate and there was an ongoing failure to identify or act upon known risks to people. Systems and processes in place were not adequate in ensuring people were protected from abuse or avoidable harm. Safeguarding concerns were not always identified and reported to the appropriate authorities placing people at ongoing risk of harm.

People were not involved in their care and risk management. People’s care needs were neglected, and care was not provided in a safe and supportive way. People were not able to do things that mattered to them. One person who had been living at the service for 11 months told us, “I have not been outside once since I got here.” In addition, the person told us they were afraid of falling but staff didn’t make them feel safe. They said, staff just say, “You'll be ok” and shut the door, this meant nobody would see if they did fall. In addition, they said they were unable to reach their call bell, and they were scared they would fall and “nobody would know for hours.”

Risks to people's health were not safely assessed, monitored, managed or mitigated. On the second day of inspection, we were informed 2 people had fallen during the night and 1 person remained on the floor. There were no falls sensor mats in place, call bells were out of reach. Staff were unable to confirm how long both people had been laid on the floor. Staff were not confident in moving and handling practices and the equipment battery failed during the process. The person was laid on the floor for 40 minutes from the point in which the fall had been identified, placing them at continued risk of harm and injury. A third person said they had fallen and were experiencing pain, however staff tried to pull the person up by their arm. An inspector intervened to stop this. Staff were unable to confirm whether they were trained in moving and handling. We observed unsafe moving and handling, placing people at risk of injury. Risks relating to the use of bedrails were not appropriately managed. We observed a person in bed wedged against the bed rails which had no protective bumpers to reduce the risk of entrapment or pressure damage. Leaders and staff did not know people’s needs and risks. The manager did not know who was at risk of falls and said they relied on the agency staff member as they “had the most knowledge of individual risk.” When we spoke to the staff member referred to, they told us they did not know people’s risks as they were unable to access the system, they had not been shown how to use it, and information from the handover was of no value. Staff had inconsistent knowledge of people’s risks, therefore we were not assured they were cared for safely. One staff member told us, “It is unsafe." Regarding monitoring, what people had to eat and drink staff told us, “We just try to remember, it’s probably not right.”

People’s skin integrity and pressure care risks were not being monitored and managed effectively, placing them at risk of harm. Staff lacked guidance to care for people safely and meet their skin integrity needs. For example, 1 person’s skin integrity care plan was inaccurate, and they had no wound care plan despite other records stating they had a wound. Another person had a pressure injury and their records relating to this were not accurate. Five people had not been repositioned in accordance with their care plan placing them at ongoing risk of harm. Risks relating to people’s food and fluid intake were not being monitored and managed effectively placing people at serious risk of harm of weight loss, malnutrition and dehydration. People were not sufficiently supported to eat and drink. Records associated with food and fluid monitoring were not accurately completed.

There was poor recording of people’s weight, food and fluid intake, and no action to identify or address concerns. There was inaccurate recording of people’s risks of choking and particular dietary needs. The provider failed to ensure effective systems were in place to assess, monitor and mitigate risks to people and keep them safe. People were neglected and placed at ongoing risk of significant harm and/or injury due to these failings.

People were not cared for in an environment that was safe. One person told us they weren’t happy, and went on to explain, “because of my room”. When their room was observed by the inspection team it was seen to be unfit for a person to live in and in a significant state of disrepair. There were no curtains, a damaged electrical socket, holes in the walls, their bed was damaged and there were broken drawers and wardrobe.

Leaders and staff had failed to take action to address the long-standing environmental issues. There was a lack of responsiveness from leaders when environmental concerns were raised. For example, concerns regarding people’s rooms were raised with the provider on the second day of inspection however we found on subsequent days those significant issues remained and had to be raised by the inspection team again.

Areas of the environment were unclean, unsafe and disrepair was evident. Many people’s rooms were in poor condition, others were unclean, stark and contained damaged furniture. For example, 1 person had equipment cluttering their room and it was in a state of disrepair. One person had a missing wardrobe door. In addition, we observed 1 person in bed with a duvet, which had no duvet cover and there was a broken set of drawers in their room. Fire safety risks were not appropriately assessed, monitored and mitigated. We observed staff did not know what the fire alarm sounded like and did not attempt to evacuate people when it alarmed. Personal Emergency Evacuation Plans (PEEPs) were not up to date. This was raised on the first day of inspection and remained an issue on the fourth day of inspection. This meant there had been a continued failure to protect people from the risk of harm or injury in the event of a fire.

Premises were not clean, suitable or properly maintained which placed people at risk of harm and injury. Systems and processes were not effective in identifying and/or addressing risks within the care environment.

There were not enough suitably qualified, competent and experienced staff on duty, or effectively deployed, to meet people’s needs and keep them safe. People’s health and support needs were consistently neglected as staff were unable to appropriately respond. One person told us, “Staff are not always available and when they are they don’t know me."

Managers and staff did not know people’s needs and risks. In addition, they did not know how many people were living at the service. Due to the lack of permanently employed staff at the care home, there was a high dependence on the use of agency staff at the service however they were not provided with the support and information they needed to carry out their roles. They told us they had not received an induction and did not know people’s needs. They had not received training regarding how to access the electronic records systems or how to retrieve information about people’s health, care and supports needs, or medicines. One staff member told us, “We don’t have the time or the resource to check people and look after them properly” and “People will not have what they need today."

We observed there were not enough knowledgeable, suitably skilled staff to meet people’s needs safely. There were not enough staff to respond to people when they needed support. For example, on day 2 of inspection a person was stood at their bedroom door distressed, crying and asking for help. They had no underwear on and nothing on their feet. Their bed was wet, and their bed covers on the floor, alongside their soiled continence wear. They said their back hurt. There were no staff available to notice the person and an inspector had to intervene and alert assistance.

Systems and processes were not effective in ensuring sufficient numbers of suitably qualified, competent and experienced staff were on duty and deployed effectively, to meet people’s needs and keep them safe. The provider failed to take action to address serious and significant shortfalls in staffing numbers and competency, placing people at serious risk of harm. Recruitment processes were in place to ensure staff were recruited safely. However, agency staff identity was not verified. In addition, staff did not receive appropriate induction, training, support, supervision or development, to enable them to fulfil their roles effectively and keep people safe.

People were at risk of harm due to inadequate infection prevention and control (IPC) practices at the service. On day 2 of inspection, 1 person was living in a room unfit for human habitation. The person was sitting in the dark, on a bare mattress, with no bedding, leaning on 2 bags containing their belongings. There was urine on the bedroom floor and faeces all over the ensuite. There were discarded, dirty plates and cutlery littered throughout, and rotting food on the bed and piled up behind the door. There was evidence of a possible infestation, with flies present. There was an overwhelming malodour in their room which permeated out into the corridor even when the bedroom door was closed. The person told us their room was “cleaned sometimes” however there was no evidence of any cleaning having taken place for a significant amount of time. Two other people were also living in rooms where fecal matter was found all over ensuite areas and door handles.

Staff told us there were not enough of them to ensure sufficient cleaning of the service and there was a backlog of dirty laundry, piled up in bags on the laundry room floor. On the fourth day of inspection staff said there would be no housekeeping staff available from 14:00 until the following morning, and there were not enough of them to clear the backlog and complete the cleaning and laundry tasks.

Infection prevention and control (IPC) concerns identified were shared with the provider on day 2 of the inspection however we found 10 days later, these had still not been addressed. For example, 1 person was still living in an extremely dirty bedroom, with urine, faeces and food remnants on the floor and surfaces. Their bathroom floor was saturated with urine, faeces and wet toilet paper, and there was an overpowering malodour which pervaded into the corridor outside the room. There were flies within the room. We found faecal matter on people’s door handles and ensuite bathrooms. One person was in bed with a lump of faeces on the floor next to the head end of the bed. There was no sheet on the bed and several clothing items were screwed up in a pile on the end of the bed. A staff member entered the room and left without taking any action to remove the faeces from the floor. We saw 1 person had scabies and staff supported them without wearing PPE. There were no barrier nursing procedures in place. This placed people at risk of harm. Equipment in use was not always clean. For example, crash mats had dirt, debris and/or spillage stains.

Cleaning equipment and clean bed linen was not always readily available. For example, on day 4 of inspection there was a shortage of clean items, such as mop heads, sheets and duvet covers. One staff member asked for clean bedding for a person, but the clean bedding shelves were empty. Systems and processes to uphold safe IPC practices were not implemented. Standards of cleanliness and hygiene in areas of the home were inadequate and the conditions people were living in, unacceptable. Risks in relation to IPC had not been appropriately assessed monitored and mitigated placing people at risk of harm from infection.

People’s medicines were not always in stock and available to be administered, this placed people at risk of harm. For example, 1 person had missed 13 consecutive doses of their diabetes medication. When people had their medicines given via a percutaneous endoscopic gastrostomy (PEG), we found the instructions did not always inform staff to give the medicine via the PEG; this placed people at risk of being given them orally, placing them at risk of harm. When people had thickener added to their drinks, to reduce the risk of them choking, this was not always recorded, therefore we were not assured the thickener was added to their drinks as needed, which placed them at risk of choking. Information to support staff to know to give people their ‘when required’ medicines was not always available. This meant people did not always get their medicines when they needed them. One person told us they did not get the medicines on time. They said, “Last night it was 00:55. I asked the night nurse for them, they said they couldn’t find them. I knew others hadn't had their medicines either because there were a few of them walking up and down and getting angry, bashing doors."

Staff were not always able to access and locate information needed to ensure people had their medicines safely. Staff were not able to tell us how to use the electronic medicines administration records effectively. Staff told us they sometimes did not finish giving people their morning medicines until nearly lunchtime, this meant their next dose of medicine might be delayed as the required time interval had not been observed. This meant people were placed at risk of experiencing pain and other symptoms their medicine was prescribed to treat. One staff member told us about time delays and people regularly missing medicines. They said, “It has taken nearly 3 hours to do medicines this morning. One person’s acute medicines have not been given for 5 days.” In addition, they told us 1 person had a urine infection and had not been given the final 2 days course of antibiotics.

The systems and processes in place for ordering, receiving, recording, administering and disposing of medicines were unsafe, placing people at risk of harm. Some medicines audits had been completed but they had not identified the concerns we found during the inspection. There were inconsistencies between some people’s care records and their medicines administration records. This meant there was a lack of accurate guidance for staff to follow, which placed people at risk of harm. When people were prescribed topical medicines, for example creams, they did not always have them applied as prescribed. This meant their skin was not being cared for properly, placing them at risk of harm. The provider had failed to take appropriate action to address issues regarding the safe management of medicines prior to and during inspection.