Alcazar Court

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.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders reviewed incidents for themes and shared learning in supervision, handovers and team meetings. Staff told us they received follow up and feedback after incidents, which helped them understand what needed to improve and why.

Relatives said the provider acted quickly when they raised concerns and kept them informed about outcomes. Staff told us they recorded incidents straight away and said the registered manager provided regular constructive feedback. One care worker said, “We would share the information during handover and inform the next of kin and the manager. I would complete an incident report.” We saw evidence of trend analysis and action being taken to improve positive outcomes for people. This showed the service encouraged openness and used feedback to strengthen safety.

The provider 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.

The provider had effective systems for assessing risks, sharing information and managing transitions between services.

Prior to providing care and support the registered manager would carry out an assessment of need to establish if the service was able to support people appropriately. Staff said they received care plans, risk assessments and visit details before starting support, which helped them prepare and provide consistent care. Leaders described working closely with families and health professionals to ensure all relevant information was shared, especially when people’s needs changed and when they accessed other services.

Relatives and people confirmed they were involved in planning and said staff knew their family members well. One person said, “[Staff] write down what they are doing, and I was involved in it. They support me the way I want to be supported,” They described smooth transitions, with staff understanding people’s routines, communication needs and risks to them from the outset. We saw that people had regular meetings with the housing provider to ensure seamless and safe connections between housing and care. This showed pathways and transitions were planned, person centred and safe.

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. The provider shared concerns quickly and appropriately.

Systems helped to protect people from the risk of harm. Staff understood safeguarding responsibilities and acted quickly when concerns were identified.

Staff had completed safeguarding training and explained clearly how they would recognise different types of abuse and report concerns without delay. The registered manager reviewed any safeguarding concerns, updated care plans and arranged retraining where needed. Staff said they felt supported and trusted leaders to take concerns seriously. One care worker said, “For safeguarding concerns, I listen to the person, make sure the information is accurate and read it back to them, so it is correct. I do not judge the person, and I report everything to the manager without delay.”

People and relatives said staff were respectful, patient and made them feel safe. Relatives told us they had confidence staff would escalate any concerns straight away. This meant that the service had effective processes to prevent abuse and respond appropriately when concerns were raised. One relative said, “My relative is safe. My relative would tell me if there were any issues or if staff were unkind.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were assessed and managed in a personalised way that balanced safety with people’s independence, preferences and choices.

Care plans and risk assessments set out people’s health needs, routines, communication preferences and known risks. Leaders reviewed risks after incidents and updated records, equipment or guidance when needed. This ensured lessons were learned and the risk of reoccurring incidents can be minimised. Staff said they monitored people for changes, such as bruising, reduced mobility or distress, and reported any deterioration immediately to the registered manager.

People were involved in decisions about risk and staff adapted support to preserve independence. For example, staff observed a person had difficulty moving safely around their flat. They escalated the concerns to the GP and specialist healthcare professionals. As a result, healthcare teams provided new equipment to help improve the person’s mobility and mitigate risks. The provider updated care plans and risk assessments. The practical impact was safer access to essential daily activities without unnecessarily restricting the person’s movement, with care plans and risk assessments updated so staff could respond consistently.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider supported people to live safely within their homes. They involved people and their families to assess risks within their home environment and any equipment they used.

Staff and the registered manager described clear processes for checking equipment such as hoists and mobility aids. Leaders carried out spot checks and audits of people’s homes to ensure environmental risks were addressed promptly.

One staff member said, “I will always check the hoists before I use them and if anything is wrong, I will tell the manager.” The registered manager told us issues found during audits were followed up and resolved. This showed equipment and home environments were monitored and maintained to support safe care.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff to support people. Care workers recorded when they started and completed a visit. This was audited by the registered manager at regular intervals, so they were able to monitor that staff were punctual and stayed the full amount of time required. People and relatives told us staff arrived on time and stayed for the correct length of time and carried out tasks as agreed. One person said, “[Staff] turn up at a specific time I am happy with this.”

Records showed that staff received training in areas relevant to their roles. Staff received regular supervision sessions and on-site spot checks. This enabled management to monitor and discuss care staff’s role, performance and development. One care worker said, “I have supervision every 3 months.”

There were policies and procedures to help recruit staff safely. The provider made checks on the suitability of potential staff. These included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and help prevent unsuitable people from working in care services.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff followed infection control processes, including washing their hands, keeping people’s home’s clean and wearing personal protective equipment (PPE) where appropriate. One person said, “Staff always wear gloves and wash their hands.”

Staff had completed training about infection prevention and control. Staff said they had enough PPE. One care worker said, “PPE is very easy to access.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People who used the service were administered their medicines as prescribed and care plans demonstrated that were prescribed medicines on a when required basis (PRN), protocols were in place.

Medicines administration was recorded electronically on the care planning system. We looked at a sample of Medicines Administration Records (MARs) and found these were completed fully indicating medicines were administered as prescribed.

People's medicine support needs were clearly documented in their care plans. One relative said, “Staff administer my relative’s medicines, and there have been no issues.” One person said, “Staff administer my tablets correctly.”

Staff were trained in the safe administration of medicines and their competency was assessed. One care worker said, “I ask the person if they are ready for their medicines. We check the medicines against the MAR, check the dose to avoid mistakes and sign the MAR.