Alderwood Care Home

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 avoidableharm.

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 69 (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 identify and embed good practice.

All accidents and incidents were reported, documented and where necessary investigated; these were routinely shared with staff through various mechanisms, for example during daily handovers, team meetings, group supervisions and ‘flash’ meetings. Flash meetings are short, sharp daily meetings attended by leaders of staff teams. Managers and staff discuss any concerns or specific events; for example, when someone new moves into the home.

Lessons learnt were completed and staff were encouraged to understand how improvements could be made. By reviewing incidents collectively this promoted discussion, and learning was embedded within the staff team.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The service worked collaboratively with external partners and other professionals to ensure people always had a safe admission to the service. Managers understood the importance of appropriate record sharing to promote continuity of care.

The service had a robust process for assessing people’s needs prior to their arrival into the service and used relevant information from other professionals to support these assessments. Important information about people was ready to share if needed, for example if a person needed to go to hospital or needed to be seen by a health professional.

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.

There were established processes in place and the provider shared concerns quickly and appropriately. All staff received safeguarding training; staff we spoke with demonstrated a high level of understanding of safeguarding concerns and actions to take should they need to make a referral. People and their relatives told us they felt the service was safe.

The provider identified when people were potentially being deprived of their liberty and complied with the basic principles of the Mental Capacity Act; applications and urgent authorisations were submitted in a timely manner. Policies, procedures and systems contributed towards effective oversight of the deprivation of liberty safeguards (DoLS) and we observed staff putting training into practice; care was provided in the least restrictive way, and people were given lots of opportunities to make informed choices.

Daily handover meetings were used to share information and ensure any new risks or safeguarding issues were communicated to staff promptly. The registered manager continued to report safeguarding concerns to the relevant local authority and had notified the Care Quality Commission, as is the law, with the relevant statutory notification.

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.

Risk assessments were regularly reviewed and promptly updated when people’s needs changed. People with specific health conditions and any associated risks were supported effectively to reduce the likelihood of avoidable harm. Risk assessments contained clear guidance for staff on how risks should be mitigated. People and their relatives told us they were actively involved in planning how risks were managed to keep people safe. One person said, “I was on the first floor, but I got moved to the ground floor when my mobility got worse. I could walk when I came in but now, I am not mobile and need help to use my wheelchair.” They felt safer being in a ground floor room and any risks were reduced.

The provider also supported people to take positive risks safely, if this was their wish. One person wanted to become more independent with their mobility and walk without supervision. Staff worked with them, assessed the risks and put appropriate measures in place to safely support this.

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 environment was clutter free and there were no malodours. Service certificates were up to date and the required improvements identified at a fire inspection earlier in the year had been addressed. We saw new fire doors fitted to many of the bedrooms on the first floor.

There was a locked gate at the top of a set of stairs to the first floor. We queried whether people could access the stairs and be at risk of falls. The registered manager informed us that people on the first floor with capacity were able to use the lift independently; where people lacked capacity they relied on support from staff. No one had shown any inclination to open the gate to try and access the stairs. Risk assessments we saw assured us that people remained safe.

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.

Staffing levels were appropriate during this assessment, with minimal use of agency when required. The registered manager had recruited to 2 new twilight care shifts, created to help keep people safe, as accident and incident analysis showed people were at increased risk of falls at this time of the day. Staff valued the support on this shift.

There had been 2 recent appointments to fill the vacant chef positions, and the kitchen was now fully staffed. All checks were in place for new recruits, including any right to work checks. The training matrix evidenced good compliance and where this wasn’t the case a rationale for why certain elements of online training had not yet been completed. For example, we noted 3 employees had commenced their employment less than 3 weeks prior to this assessment and were still within the induction timeframe.

The provider assessed and managed the risk of infection and were compliant when last audited by the local authority in February 2025, achieving a score of 96%. Whilst they detected and controlled the risk of infection spreading, feedback we received indicated they did not always share concerns with appropriate agencies promptly. There had been a delay in reporting an influenza outbreak. Following the incident all staff had been reminded of the correct processes to follow in the event of any suspected infections and the importance of timely intervention. The health professional told us they were satisfied with the registered managers response and actions they had taken to address the concern.

We saw supplies of personal protective equipment (PPE) safely stored within bedrooms and storage areas of the home; domestic trollies were also well-stocked. There was a weekly GP visit; staff were able to make referrals, or seek support and advice, in the event of any suspected infections or other health concerns people might have.

People received their medicines as prescribed. The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences, however, we saw anomalies with temperature records relating to the clinical room. Staff were noting and recording the temperature of the clinic room, where medicines were stored, on a daily basis. Daily temperature monitoring and recording are essential, especially if room temperatures risk exceeding 25 degrees, as this can affect product stability and reduce the effectiveness of some medicines.

There were occasions when the temperature of the room had exceeded 25 degrees, but it wasn’t clear what action had been taken by staff. We brought this to the registered manager’s attention who assured us that a fan installed in the medicines room was used to lower the temperature when this exceeded 25 degrees. Staff were not recording additional temperature checks when required, to evidence the decrease in temperature. We were supplied with a revised template and assured that additional temperature checks would be recorded in future.

Any issues identified, for example, low stock of a time sensitive medication, were discussed in staff meetings, flash meetings and included on an action plan for follow up.