Alexandra Park

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 inspection we rated this key question requires improvement. Following this assessment, the rating has remained 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 provider was in breach of 3 legal regulations in relation to safe care and treatment, safeguarding people from abuse and improper treatment and governance.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives expressed concerns that improvements were not being made to ensure people experienced positive outcomes and had their care and support needs met. A relative told us, “I have had phone calls from CQC before and we say the same things – it doesn’t seem like they [the provider of Alexandra Park] learn.”

The culture at the service was not positive, with poor communication being raised as an issue by relatives.

Several staff told us that improvements had not been made and there were still ongoing issues with the service and culture.

Whilst accidents and incidents were recorded individually; these were not all recorded centrally to ensure management oversight and identify if there were any themes or trends, so action could be taken to help prevent any reoccurrence.

Management staff told us, “Whilst all accident and incident forms are reviewed as soon as staff hand them in there is sometimes a delay in uploading these to [name of computerised system]. This will be reduced once the new team leaders and deputies are in place as this will be allocated to them for the initial input.”

The failure to ensure there was evidence of management oversight and review, placed people and risk of avoidable harm.

A representative from the local authority told us there had been a lack of evidence provided to demonstrate that the improvements required had been implemented and the service remained in organisational safeguarding measures. This meant the local authority was monitoring the service and supporting them to ensure the correct procedures were in place to keep people safe.

An effective system was not in place to ensure lessons were learned and improvements were made. This is the 8th consecutive time the provider has failed to achieve a rating of at least good in the safe key question. This meant action had not been fully taken and embedded to improve the service and ensure people achieved good outcomes in this area.

Accident and incident analysis was not always detailed to help identify any themes or trends so action could be taken to reduce the risk of reoccurrence. The manager told us their Positive Behaviour Support (PBS) team carried out a detailed analysis of incidents, however, this was only completed after a PBS referral was made.

Relatives raised concerns regarding communication systems at the service which posed a risk to people’s wellbeing.

Several staff told us that management communication systems needed to improve to ensure people experienced safe and effective care and support.

Most health and social care professionals told us that communication with the service was not good. A health and social care professional told us that communication had not been effective whilst they had been trying to organise a person’s discharge from the service. Another health and social care professional told us, “It has at times been difficult to get responses to correspondence in a timely manner, both for my existing clients living there and for new referrals made to the service.”

Due to the management structure in place at the time of the assessment and lack of a deputy manager and team leaders; communication systems with stakeholders, staff and relatives had not always been effective.

Management staff told us a new manager had been appointed together with 2 deputy managers and team leaders to ensure there was effective oversight and management of the service.

People were not safe from the risk of abuse. We identified concerns regarding how people’s monies were managed. A relative raised concerns about the management of their family member’s finances. We passed these concerns to safeguarding and the police.

Staff told us there was a lack of guidance relating to managing people’s finances to ensure people were protected from the risk of financial abuse. A staff member said, “There’s no guidance, the staff just muddle their way through.” Several staff told us they had not completed specific training in relation to supporting people who sometimes exhibited distressed behaviour.

This training helps staff support people with their distressed behaviours and helps ensure staff follow non-abusive psychological and physical interventions.

We did not observe any safeguarding concerns during our site visits.

An effective safeguarding system was not fully in place.

This is the 3rd inspection that the provider has been in breach of the regulation in relation to safeguarding people from abuse and improper treatment. We have taken this into account when scoring this quality statement.

The service was in organisational safeguarding.This meant the local authority was monitoring the service and supporting them to ensure the correct procedures were followed. A representative from the local authority told us there had been a lack of evidence provided to demonstrate that the improvements required had been implemented.They also explained there had been a delay in notifying them of certain safeguarding incidents.

A robust system was not fully in place to ensure people were protected from the risk of financial abuse. There was a lack of guidance relating to people’s contributions to staff expenses when people were being supported socially. We also identified shortfalls relating to financial records and audits.

Several people’s care plans required staff to have undertaken specific training to help them support people with their distressed behaviours and ensure staff followed non-abusive psychological and physical interventions. However, training records and management staff, confirmed that not all staff had completed this training. A staff member had raised concerns in a person’s daily records that another staff member had been restrictive in their practices whilst they were supporting the person in the community. This staff member had not undertaken the training specified in the person’s care plan.

Some relatives told us that people did not always have the same core team of staff who knew their family member well and could support them safely. 2 relatives said staff did not always “shadow” experienced staff to help them understand the person’s needs and routines before fully supporting them on a shift. Some relatives said they did not feel as involved as they should have been. Relatives also told us communication was poor at the service. These issues posed a risk to people’s safety and wellbeing.

We identified shortfalls with the management of risk relating to medicines, people’s monies, the environment, assessing people’s moods and nutrition and hydration which also posed a risk to people’s health, safety and wellbeing.

Staff raised concerns about the safety of a person at night. Management staff told us that a risk assessment had not been completed to document the actions taken to mitigate the risks.

Staff told us that a person had lost weight. There was no care plan or risk assessment in place to document the actions which were being taken to monitor the weight loss.

A wire fence surrounded the service which posed a risk of unauthorised access and 2 people’s doors were kept open at night.

At our previous inspection we found that an effective system to assess and monitor risk was not fully in place. We issued a warning notice and told the provider they needed to take action to improve.

At this assessment, an effective system was still not in place to ensure risks relating to people’s care and support were assessed, monitored or managed. Some care plans stated staff should complete a mood assessment before supporting people to access the local community to ensure their safety. These assessments were not recorded. 1 person’s care plan did not demonstrate that advice from the speech and language therapist about the texture of food had been followed. A 2nd person’s care plan stated they had previously become ill when they drank too much. Details of the maximum amount of fluid the person could have, were not recorded. Staff explained that a 3rd person had lost weight; there was no care plan or risk assessment in place in relation to this weight loss and associated risks. Care records relating to a fourth person picking up/chewing or swallowing cigarette butts were contradictory about the measures in place to reduce the risk of harm. These shortfalls posed a risk to people’s health, safety and wellbeing.

People and relatives did not raise any concerns about the environment. However, handover records stated staff left 2 people’s doors unlocked at night and curtains open, so it was easier for staff to check those people overnight. Whilst a wire fence surrounded the service; there was still a risk of unauthorised access which posed a risk to people’s safety. This risk had not been considered.

Management staff told us and records confirmed, they had requested waking night support for 1 person due to behavioural and environmental risks. However, this support had not been agreed by the local authority. Management staff told us a risk assessment had not been completed to document the actions taken to mitigate the risks.

Whilst a wire fence surrounded the service; there was still a risk of unauthorised access and 2 people’s doors were kept open at night.

The environment did not always promote people’s dignity and action to remedy the environmental issues had not always been taken in a timely manner. We visited a person and noticed they did not have a toilet seat. There was disused equipment and a toilet seat in their garden. They also had no curtains or blinds fitted because of the risk of ingestion. There were black bags covering the outside of another person’s windows which we had observed at our last inspection.

Management staff explained that due to the nature of the person’s condition, they often broke their toilet seat and a specialist toilet seat was going to be fitted. They also told us they were obtaining quotes for special integrated internal blinds which people could not access and ingest.

Whilst the 'campus style' setting did not align with current best practice; action had been taken since our last inspection to improve the environment. Other people's bungalows had been refurbished to meet their individual needs.

An effective system was not in place to ensure risks relating to the environment were assessed and actioned. A person had been found outside of their bungalow late at night. Whilst management staff had requested funding for waking staff to support the person, this had not been agreed by the local authority. A risk assessment to document additional actions taken by staff to ensure the person’s safety overnight was not in place. In addition, in August 2024, the manager had emailed a health and social care professional stating they would look to install a safety lock which would release in the event of an emergency if waking night staff had not been agreed. This was not in place and the person’s door remained open during the night. This posed unnecessary risk to the person which had not been addressed in a timely manner.

Several relatives said that people did not always have the same core team of staff and raised concerns that people did not always receive their assessed hours. They also said people were not always able to access the community because there were not always enough staff who could drive. 2 relatives said staff did not always “shadow” experienced staff to help them understand person’s needs and routines before fully supporting them on a shift.

Several staff told us they had not completed specific training in relation to supporting people who sometimes exhibited distressed behaviour. A staff member also told us that they had not received a debrief following a serious incident to help identify lessons learned and whether any further support was required.

Management staff told us that a training programme was in place and staff were supported with training and support to meet people’s needs. Additional training and updates around record keeping had been/was being organised and completed by staff.

Staff explained that our presence would distress some people, so we were unable to observe their care and support. Where we did observe interactions between staff and people, people appeared comfortable in the presence of staff.

An effective system was not in place to ensure staff were suitably trained and skilled. Several people’s care plans required staff to have undertaken specific training to help them support people with their distressed behaviours. However, training records and management staff confirmed that not all staff had completed this training.

People’s records sometimes contained conflicting information about the texture of food provided which meant it was not always clear that people were receiving food in line with their assessed needs. Following our feedback, management staff told us staff had been assigned training on the ‘International Dysphagia Diet Standardisation Initiative’ which provides guidance about common terminology to describe drink and food thickness.

Records did not evidence that staff were supported to have a debrief following a serious incident to help identify lessons learned and whether any further support was required.

Checks were carried out before staff started work at the service. However, records did not evidence that timely action was taken to refer a staff member to the appropriate authority following concerns raised about their conduct.

A new electronic staff scheduling system had been introduced to plan rotas and schedule staff on duty. At the beginning of our assessment, it was not always possible to ascertain whether people had received their assessed hours. However, following the implementation of the new system, staff allocations were clearer.

Relatives did not raise any concerns about infection control procedures at the service.

Staff told us they had access to and used PPE. Staff had undertaken infection control training.

We observed that action had been taken following our previous inspection regarding infection control and cleanliness.

We identified issues relating to infection control practices for 1 person regarding hand hygiene and laundry processes. We provided feedback to management staff about these issues for their information and action.

An effective infection control system was now in place. Processes had improved following our previous inspection.

Whilst people did not raise any concerns about medicines, we identified shortfalls with medicines management which posed a risk to people’s health, safety and wellbeing.

Staff did not raise any concerns about medicines management.

Staff ensured people's behaviour was not controlled by excessive and inappropriate use of medicines. Staff explained that management agreement was sought prior to administering any medicines which were prescribed on a when required basis.

We did not observe any concerns with medicines.

An effective system was not fully in place to evidence that medicines were managed safely. A person’s regular medicine had been changed to ‘when required’ at the request of their relative; however, this change had not been authorised by the prescriber of this medicine. A second person’s ‘when required’ guidance was missing. In addition, a risk assessment in relation to medicines was not in place when the person’s relative took them out at short notice. This person was also prescribed a medicine in the morning, however staff signed to record they administered it in the evening. A third person’s medicines administration record (MAR) contained conflicting information about the dosage of a medicine and staff had signed for the person’s medicine in advance of administration. The amount of medicine prescribed for a fourth person as a variable dose was not always recorded. In addition, they were prescribed a medicine to be taken in the morning before food and another medicine to be taken after food, however, staff explained because the medicines were in one blister compartment, these medicines were administered together.

This is the third time the provider has been in breach of the regulations in relation to medicines management.