Alice House

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 inadequate. At this assessment the rating has changed to 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.

At the last assessment in September 2024. We found the processes in place to monitor standards and to identify, record, and learn from incidents were not effective and placed people at risk of harm. At this assessment we found improvements had been made. Some people who lived at the home, who were involved in incidents had been moved to other homes as their needs could not be met. The provider conducted an overall review of people’s care and looked through accidents and incident records retrospectively. Action had been taken to learn from these accident and incidents, and records confirmed the provider took action to prevent occurrence and identify trends. People’s care records contained information about behavioural triggers and the strategies the staff should follow to diffuse behaviours.

We received positive feedback from staff about the changes that had been made. One staff member told us, “Its much calmer and relaxed here now and we feel able to meet the resident’s needs. I feel much more confident when caring for people, with behaviours that may escalate. The registered manager told us they had worked with the provider to continuously review incident and accident logs and update risk assessments.

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.

At the last assessment carried out in September 2024, we found the service had not always assessed people's care needs before they moved to the home. We found evidence of gaps and incomplete assessments and handover information. Some professionals had described a difficult relationship with the management team. At this assessment we found that improvements had been made. We reviewed some people’s care records to see how people had been assessed prior to their admission. We found evidence of completed preadmission assessments. The registered manager told us they carried out the assessments on paper and then, typed the information into the electronic care records system. The information helped to decide if the home could meet the person’s needs, this helped to form the person’s care plan and to identify any risks. Records relating to people who lived at the home were up to date. This contained information about people’s care needs and resuscitation wishes.

The staff continued to take part in handover meetings and since the last assessment, the handover process had changed. The senior staff member on duty gave handover by using the electronic care records system, using formal records. They were able to highlight any concerns around people’s wellbeing and hand this over to the next shift. We spoke to staff to find out if improvements had been made. One staff member told us, “The handovers are more structured, and we have the time to discuss changes in the resident’s wellbeing. We can look over the past few days for an overview.”

The GP surgery continued to support the home with weekly visits. The deputy manager planned a list of people that needed to be seen. This contained information about why the visit was needed, recent weights and general observations and no gaps were identified.

At the last assessment, some professionals told us they had some concerns about the homes willingness to engage with health professionals, and they felt resistance. We sought feedback from professionals during this assessment, which was positive. One professional was keen to speak with us. They described a much-improved relationship with senior staff. They said, “Things are much better here, and I feel welcomed at the home and the staff are brilliant. I have a list of patients to see all prepared ready for me. The list is informative, and the staff know people well and any changes in wellbeing are recorded. They have worked hard, and it makes it much easier for me to make judgements regarding people’s wellbeing.”

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.

At the last assessment in September 2024, we had serious concerns that people were not consistently kept safe, from the potential risk of harm. Systems and processes to make sure people were protected from abuse and neglect were not effective or consistently used. We found some people had unexplained bruising and injuries that had not been recorded on incident and accident forms. Safeguarding referrals had not always been reported to the local authority. We issued a warning notice to the provider after the assessment. A warning notice is part of enforcement action taken by us, where serious concerns are identified. We followed up the warning notice in March 2025 which included us looking at some parts of safeguarding, where we had serious concerns. We found improvements had been made. However, we did not look at the quality statement of safeguarding.

At this assessment we followed up on the previous concerns and we found improvements had been made. The provider had taken the concerns seriously and a full audit of safeguarding was carried out. Safeguarding concerns involving accidents, incidents and unexplained bruising were reported to the local authority safeguarding team retrospectively. Action was taken to safeguard the people that were involved. We reviewed people’s care records and found evidence that incidents, accidents, and injuries were reported appropriately. Accident and incident records clearly recorded what had happened, known injuries and who was involved. The information was also recorded in people’s daily notes. Investigations took place where people had come to any harm. All completed accident and incident forms were sent to the registered manager to review. They checked, these were fully completed, and the appropriate safeguarding referrals were made. This was not closed until the appropriate investigations and action had been taken.

We spoke with relatives to gain feedback about safeguarding. One relative told us, “I was worried after the inspection you did last year. I have no concerns, and I have noticed I am made aware now if anything is wrong.”

Staff confirmed they continued to have access to safeguarding procedures and had received training. We received positive feedback regarding safeguarding processes. One staff member said, “We are now recording much better and we have had training regarding how to complete incident forms. If we have not filled the forms in correctly, we are asked questions and given feedback. The number of concerns has reduced.”

We spent time observing in the home on both days. We did not identify any safeguarding concerns. People’s care records confirmed learning from safeguarding incidents was taking place. Body maps were being used to record any bruising or injuries, which were being monitored by the registered manager and provider.

The Mental Capacity Act 2005 provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The service was working within the principles of the Mental Capacity Act and if needed, the service had the required legal authorisations to deprive a person of their liberty.

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.

At the last assessment in September 2024, we were not assured risks to people were always sufficiently assessed and mitigated, with clear guidance for staff to follow. We observed environmental risks were not always safely managed. Risks relating to people’s health conditions were not appropriately risk assessed. We also received mixed feedback from the staff in relation to managing risks.

At this assessment, we found improvements had been made. The registered manager told us that since the last assessment, care plans and risk assessments had been reviewed and updated. We checked risk assessments and the care plans of some people. The assessments contained clear guidance for staff to follow. Risks relating to people’s nutrition, weight loss and health conditions were being safely managed. Some people at risk of malnutrition were being weighed weekly and an explanation around the weight loss was provided in a monthly analysis. We looked at people’s weights and did not identify any concerns. Records confirmed the staffs record keeping had improved. Information about those people who may be at risk and the action taken was recorded. This included a discussion with health professionals, such as the GP. Risk assessments around managing people’s weight loss were up to date. Where people had a health condition, such as diabetes, there care plans advised the staff how the person’s medical condition was being managed. This information included who was monitoring their glucose levels and how the associated risks were managed. At the time of the assessment nobody who lived at the home were at risk of choking.

Staff gave us feedback about how risks were managed for people. They told us, “All risk assessments were reviewed, and we have got to know people’s triggers and information about health conditions.” and “I feel we are doing well and balancing wishes against needs. Things have improved and we are focusing on prevention."
 

People had in-depth risk assessments in place to help the staff manage behaviours that may affect themselves and others. This linked with managing environmental risks as most people were living with a diagnosis of dementia. At the previous assessment, we identified objects had been used during incidents and altercations with people. Sufficient action had been taken to reduce these risks and prevent these incidents from happening again. Items that could pose a risk to people were locked away and staff were supervising areas of the home to prevent altercations. The focus was preventative action being taken to help people engage with activity and stimulation.

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

At the last assessment of the home in September 2024, we found the provider did not always sufficiently assess risks within the environment. We found fire drills had not been carried out, radiators in bathrooms were not covered with exposed hot water pipes. We observed sticks, tools and an iron had been left unattended and there was a risk this could have caused harm to people, living with dementia. At this assessment we found improvements had been made.

People could not tell us their views of the environment. We spent time looking around the environment, including the garden and we found items such as garden tools, sticks and the iron had been safely locked away. The staff were allocated areas of the building to work in, and the communal kitchen was supervised by the staff.

We discussed fire safety with the registered manager and checked fire drills and staff training records. Fire drills were being carried out regularly. This was as part of the induction process with ongoing refresher training. A log of fire drills was kept and this recorded the staff who had attended. Fire training was also being carried out annually. We checked the homes fire grab bag, which was used in the event of an emergency. The bag now contained an up-to-date list of people living at the home and information about people’s mobility, should the home need to be evacuated. The fire grab bag was kept in the home entrance area; we spoke to the operations director about the risk this posed with data protection. This was immediately moved inside of the building, during the inspection visit.

Radiators that posed a risk were covered and one radiator had been fully removed. Hot pipes had been boxed in and covered to reduce the risk of harm to people. The provider carried out checks of the environment and the registered manager was keen to show us the improvements. The provider carried out safety checks of the premises. This included checks of the fire equipment, gas and electrical safety.

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.

At the last assessment carried out in September 2024, we found that staffing levels were not sufficient to ensure peoples safety and needs were met. We observed incidents where a person came to harm due to the lack of staff observation. Recruitment checks were not safe, and we identified gaps with pre-employment checks.

At this assessment we found improvements had been made. The registered manager told us that the occupancy of the home was lower due to having vacant beds. However, the staffing levels had been maintained and not lowered. Improvements had been made with sickness and annual leave being covered with staff as overtime or by using bank staff, to avoid any shortfalls. The home was using a dependency tool to help calculate the needs of people against the number of staff needed. People’s care needs were reviewed monthly and after any incident, fall or hospital admission. We spent time with the registered manager and discussed people’s needs. At the time of the assessment, nobody required hoisting or 1 to 1 care. The registered manager and operations director told us a human approach was still needed, and this was being monitored ongoing. Despite the tool showing the home had the correct staffing numbers, the operations director planned to increase the staffing levels early mornings and evenings. This was being increased due to feedback from the staff.

We spent time observing in the home and found that the environment was calmer and people were relaxed. Mealtimes were a social time with the staff sat assisting people. People were served their meals in a timely manner, and the atmosphere was no longer chaotic. We did not identify any concerns in relation to people’s wellbeing. The staff were allocated to different areas of the home to work in. This helped to manage people’s behaviours as the staff were able to supervise people and de-escalate behaviours.

We received positive feedback from relatives about staffing levels in the home. One relative told us, “Things are better, and I have noticed the staff seem are much more available. I do not have any complaints.” The people we spoke with, did not raise any concerns about staffing levels.

The staff were caring an attentive towards people. We spoke to them about staffing levels at the home. They told us, “I used to dread coming in some days, but it is very different now. We have a good team and all help to cover when its needed. We do not really go short,” “It has improved a lot, although we do still have busy times. The staffing levels are being increased again soon. We have less residents now and the needs of people are not so high.”

Recruitment checks were safe, and pre-employment checks were carried out. Since the last assessment, the provider had carried out an audit of staff files. They identified where the gaps were with staff recruitment checks. This was followed up where needed and risk assessments were put in place. For example, if only one reference was received this was risk assessed. A staff recruitment spreadsheet was in place which contained information and dates in relations to the pre-employment checks carried out. The records confirmed all staff had a Disclosure and Barring Service (DBS) check, prior to starting work. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. We did not identify any shortfalls.

Staff were provided with appropriate training and supervisions. The registered manager told us training was ongoing and any additional opportunities for specialist training was provided.

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.

At the last assessment carried out in September 2024, we were not assured procedures in respect of infection control practices were effective. We identified a lack of personal protective equipment (PPE) was available and used laundry was not stored safely. At this assessment we found that improvements had been made. We checked the available stock of PPE, and we found bathrooms and toilets had replenished stock, such as aprons and gloves which were kept in cabinets. The open laundry tubs had been removed and replaced with laundry trolleys with lids. These were colour coded to reduce the risk of cross contamination. Soiled laundry was placed in red bags and washed separately. We did not observe any poor practice in relation to the PPE use by the staff. PPE was safely disposed of in clinical waste bins. We spoke with the staff about infection control practice and PPE. They told us they had not experienced any issues with the PPE stock. One staff member told us, “We have PPE available to use and we have not had any issues. I always wear PPE when providing personal care.” We spoke with relatives about the cleanliness of the building when they visited. They did not have any concerns.

We reviewed cleaning schedules and found these were in place and completed by the staff. Infection control audits continued to be carried out by senior staff.

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.

At the last assessment in September 2024, we identified serious concern with people’s medicines, which included controlled drugs. This related to how medicines were stored, administered, and were disposed of. When we visited the home in March 2025, we looked at some parts of medicines, where we had serious concerns. We found improvements had been made. However, we did not look at the full quality statement of medicines.

At this assessment we found improvements had been made. Medicines were now being stored and disposed of safely. Discontinued controlled medicines were now being safely disposed of. A log was maintained of these medicines, the name of the person and the quantity. All controlled medicines were stored safely in a cabinet which was secure and double locked. All medicines which entered the building were double signed by the staff with robust checks. Since the last assessment, the number of people prescribed controlled medicines had reduced. Medicines errors were now being reported and recorded formally, with the appropriate action taken.

Pain patches continued to be used to manage some people’s pain. At the last assessment, the patches were not being rotated on people’s bodies, and the location of the patch was not changed each time. We followed this up at this assessment and we found body maps were in place, to show the staff the position the patch was last applied. The home no longer kept a stock of homely remedies; all medicines were labelled for individual use. Fridge temperatures were checked and records confirmed they were taken and within a safe range.

Medicines had robust oversight from senior staff, the registered manager, and the provider. Audits were undertaken of medicines records, stock, and the storage.