Alderbrook 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 avoidable harm.

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

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although incidents and accidents were recorded on the services chosen electronic system, required follow-up actions were not always taken in a timely manner‑. For example, following falls, care plans and risk assessments were not always updated to reflect changes in people’s needs or to inform safe ongoing care.

There was limited evidence that incident trends were analysed, or that contributory factors were routinely explored. Lessons learned were not embedded to prevent reoccurrence. Staff told us they did not always report altercations between people unless they were considered serious, due to time pressures. This indicated a culture that did not sufficiently prioritise safety reporting. Appropriate records were not always completed to support analysis of behaviours that may indicate distress or unmet need, further reducing opportunities for organisational learning. One staff member told us, “We don’t complete paperwork for every incident that happens, we just don’t have the time.”

Overall, the systems in place did not support a proactive safety culture. The lack of timely review, analysis and structured learning reduced the provider’s ability to identify patterns, implement improvements, and assure the safety and wellbeing of people using the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People were not always supported safely when they were distressed, and staff did not consistently have access to the information they required to meet people’s communication needs.

Overall, the provider did not consistently manage or monitor people’s safety or ensure continuity when people moved between services or required input from external professionals. These shortfalls placed people at increased risk of receiving care that did not fully meet their needs or respond to changes in their condition. One person told us that they were planning to move, however they did not know when this was, when asked if they had been involved in planning this transition their response was “It’s impossible to find out what going on here, no one knows what going on.” One staff member told us, “Due all the changes in management information gets lost and, things are just not being managed well, we get moved about so there is no continuity.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider did not always share concerns quickly and appropriately.

Several staff told us they did not have access to safeguarding policies, and some relied on training from previous employers.

We received mixed feedback from staff regarding safeguarding training. One staff member told us, “I have undertaken safeguarding training, and I am aware when and how to report a safeguarding.” However, another said, “The safeguarding policy available, nobody has explained to me in detail how I can report and how I would report them. I have not received safeguarding training at all since I started.”

The provider did not ensure that staff were consistently informed, trained, and supported to fulfil their safeguarding responsibilities. These shortfalls increased the risk that concerns would not always be recognised, escalated, or acted upon in a timely and appropriate manner, which could impact on people's safety and wellbeing.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Staff told us they felt inadequately prepared to support people whose behaviours indicated distress. While some training had been delivered, this was not consistent, and not all staff had attended. Those who had completed training reported it lacked the required information they needed to support people appropriately. Planned follow-up training had not taken place. This meant staff were not consistently equipped with the knowledge or skills required to manage risks safely.

We observed that sensor mats were not always positioned correctly to ensure that staff were alerted to people requiring assistance.

One person’s care plan stated they did not use words to communicate, yet no communication plan had been developed to guide staff. This resulted in staff being unable to interpret the person’s distress causing avoidable anxiety for the individual.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The home environment was clean, well maintained and equipped with appropriate safety features such as window restrictors and radiator covers.

People’s rooms were personalised to reflect their preferences. Personal Emergency Evacuation Plans (PEEPs) were completed for people, and a fire risk assessment had been carried out, however not all staff had completed fire safety training; one member of staff told us they would not know what to do in the event of a fire. This demonstrated that the provider could not be assured staff would respond safely and effectively in an emergency.

Environmental checks, including fire safety checks, were being completed, and the provider had sought support to improve the organisation and accessibility of health and safety documentation. However, these measures did not sufficiently mitigate the risks associated with the gaps in staff training and competence in managing safety within the environment.

The provider did not make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not work together well to provide safe care that met people’s individual needs.

Although recruitment processes were safe, the provider did not ensure staff received the support, supervision and development required to perform their roles effectively.

People and relatives raised concerns about staffing levels and the capability of some staff. Staff told us that the number of staff on duty did not always meet the needs of people living at the service, particularly during busy periods and at weekends. They reported that staffing levels were often reduced on evening and night shifts, which impacted their ability to provide safe and responsive care. Staff feedback indicated that people with high levels of need were not consistently supported because staffing arrangements did not take account of people’s complex needs. Although the dependency tool and staff rotas showed appropriate amounts of staff were deployed, upon observation it was clear that people’s needs were greater than the dependency tool had calculated.

The provider did not ensure that mandatory training and specialist learning were completed by all staff. Several gaps were identified in essential training areas, including diabetes, catheter care, stoma care, and communication. This meant staff did not have the knowledge required to support people safely.

Overall, improvements were required‑ to ensure staff were deployed effectively, skilled appropriately and supported to deliver safe, high-quality care.

The provider acknowledged the concerns raised and took immediate action with regards to training and staff supervision.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Not all staff had completed infection prevention and control training, which meant the provider could not be assured that staff had the required knowledge to minimise the risk of infection spreading.

We observed that meals were not always covered when taken to people’s rooms, which exposed individuals to avoidable contamination risks. Personal Protective Equipment (PPE) was available for staff delivering personal care and for those cleaning high risk areas, and staff were seen using PPE correctly, including during donning and doffing procedures.

The home was visibly clean throughout, and relatives provided positive feedback about the overall cleanliness and hygiene of the environment, describing it as modern and well maintained.

While the provider had implemented some effective measures, inconsistent staff training and unsafe practices in food handling indicated that infection prevention and control arrangements did not fully ensure people’s safety or consistently prevent avoidable risks.

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.

Medicines, including controlled drugs, were stored safely and securely and stock was managed well. Temperature monitoring was completed daily in areas where medicines were stored to ensure they were stored in accordance with manufacturer’s guidelines. There were good processes in place to order and obtain medicines, and arrangements were in place to obtain advice out of hours.

There was some inconsistency in the administration of time sensitive medicines. Usually, time sensitive medicines were administered in a timely manner. However, on some occasions they were given later than scheduled, so improvements were needed in this area.

Staff had good knowledge of a service users’ requirements for thickener to be added to liquids to prevent the risk of choking, however we found that the use of thickener was not recorded. The management team told us that this was in the process of being implemented.

Medicines care plans were detailed, person centred and had sufficient information for staff about how to support people manage their conditions. Protocols were in place for medicines that are administered ‘when required.’ However, some of these lacked detail. The provider addressed this promptly.

Patch rotation charts were in place for people prescribed patches and body maps were used to support and document the application of creams.

The provider followed best practice where anyone require medicines to be given covertly.

We saw good evidence of monitoring people for specific conditions. For instance, blood glucose monitoring records prior to insulin administration and blood tests for a someone who was prescribed a blood thinning medicine.

Training and competency records were completed for all care workers that administered medicines and medicines audits were completed thoroughly, with evidence of improvements being made. Medicines related incidents were well documented, recorded in a timely manner, escalated appropriately, and shared with staff to prevent future occurrences.