Alsley Lodge

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 81 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Processes were in place to ensure safety incidents were appropriately investigated and reported, and outcomes shared with the team. Records held a good level of detail about incidents and actions taken; and staff confirmed they were involved in debriefs, with links to information being sent to the whole team.

Managers had implemented excellent systems to ensure risks were well managed and seen as an opportunity to learn and improve. Using a falls analysis tool and heat maps, they had identified falls occurred more regularly in people’s bedrooms. As a result, they worked closely with the appropriate healthcare partners to ensure the right aids and adaptations were in place, which contributed to a decline in falls over several months.

Staff were very transparent when incidents occurred. A healthcare partner told us, “On the rare occasions when something has gone wrong, they have acted quickly to inform us and have been open and transparent. We’ve found them to be collaborative and genuinely committed to continuous improvement and people’s safety.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored, and continuity of care was prioritised.

Staff planned and organised care and support with people and their relatives, to ensure there was a positive, collaborative and joined up approach when people moved into the home. A relative said, “It was a really good transition. Prior to moving in we came to have a look around. [Registered manager] sat with us. I was quite impressed with the way they spoke to [person]. They have dementia and [registered manager] managed to trigger memories from years ago. It put us all at ease.”

Managers completed pre-assessment records, which included robust information about people’s needs, preferences and personal histories. Information about new referrals was shared with staff in daily handover meetings, so they were fully aware of people’s needs before they moved into the home.

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.

All staff had access to training and evidenced a strong understanding of safeguarding. Digital systems had been designed to triage incidents against local authority guidance, to determine whether or not a safeguarding referral was required.

The registered manager ensured people were supported when they experienced abuse or neglect. At the time of our inspection, the registered manager was supporting a family to share concerns about an unsafe discharge from hospital.

Closed-circuit television (CCTV) was used to monitor communal areas, to help deter abuse and monitor people’s safety. Records were in place to evidence people’s human rights and data protection regulations had been considered.

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

Staff evidenced an excellent understanding of risks relating to people, and confirmed they had the appropriate training in topics such as choking, diabetes and falls.

Managers ensured there was a balanced and proportionate approach to risk which respected choices people made about their care. For example, a person was cared for in bed but expressed their wish to go outside and enjoy the fresh air. They took a multi-disciplinary approach to reviewing risk and sourced a specialist chair, enabling the person to spend a short amount of time outdoors each day and improving their wellbeing.

Staff responded positively when people communicated their needs, emotions or distress. A person was becoming quite anxious during our inspection and staff were observed to offer reassurance to the individual, preventing further agitation or distress. Their care plan prompted staff to respond in a person-centred and dignified manner, by engaging them in meaningful conversations, providing distractions and using points of reference to help them reorientate.

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 ensured facilities, equipment and technology were monitored and well-maintained. During our inspection, we observed the environment to be safe and secure. A maintenance person was available to conduct scheduled maintenance or repairs, and regular safety checks were in place. External servicing was carried out within the required timeframes.

Staff received training in fire safety and attended regular drills. A staff member said, “We have fire drills weekly, training as well. [Registered manager] will do random evacuation practices.” The registered manager explained bedroom allocations and zoning had been considered, to ensure evacuations could be carried out more effectively, improving people’s safety in the event of a fire.

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.

The provider had recruitment processes in place to make sure staff were recruited safely, and robust inductions helped ensure they had the skills and capabilities to meet people’s needs. Staff confirmed they had access to a good level of training, received regular supervisions and felt well supported.

Managers used established dependency tools to assess required staffing levels, based on people’s individual needs. A review had resulted in additional staffing and managerial support being introduced at key times, to help improve the safety and quality of care. A relative told us, “Staffing levels seem good and there’s always someone around. [Person] has never expressed any concerns about having to wait a long period for help.”

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.

There was an effective approach to assessing and managing the risk of infection. Housekeeping staff were available, and the service was observed to be clean and tidy throughout. A relative said, “Cleanliness is very good. [Person’s] room is always clean. [Person] would put dirty clothes away, but staff were really reactive when we mentioned it.”

Staff had access to infection prevention and control (IPC) training, and an IPC lead supported the team. Personal protective equipment, soluble laundry bags and hazardous waste bins were provided to promote good levels of hygiene.

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.

The provider had robust medicines policies, procedures and systems which followed current legislation and best practice. A healthcare partner said, “There are clear systems in place for ordering, recording and returning medicines and these are followed consistently. Medication records are well maintained, and we are made away of any unused or expired medicines. Overall, the approach to medication management is safe, efficient and collaborative, helping to ensure the best outcomes for residents.”

Digital systems were used to manage and record medicines ordering, administration and disposal. The system generated automatic alerts which reduced the risk of medicines errors and enabled managers to have good oversight of any delayed or missed medicines. Medicines, including controlled drugs were stored securely and the deputy manager conducted regular checks and audits.