Archived: Alderwood L.L.A. Limited - Hayway

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment, the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

During our assessment, we saw evidence of continuous learning throughout the service. Leaders had identified additional concerns to that raised within recent whistleblowing disclosures, and been proactive to address, rectify and prevent recurrence.

This was then shared with staff during team meetings to ensure learning was filtered to people directly caring for people using the service.

We were assured that systems and processes in place to investigate and learn from incidents, events and concerns were effective.

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.

The provider had tools and processes in place to aid a smooth transition in an emergency, including an emergency bag equipped with items to help in an emergency. We found that the provider had developed Personal Emergency Evacuation Plans (PEEPs), with key information on how to support people during an evacuation. These initially weren’t kept in a location people could access promptly; however, this was rectified immediately during our assessment.

When people’s needs were changing, the manager referred people to internal and external professionals, to ensure people got the right support. For example, one person had recently begun to experience a change in mobility needs. Staff documented and reported their observations around this, and managers had completed referrals to relevant health and social care professionals to ensure a holistic response to their change in need.

As an additional measure to ensure continuity, the provider operates a paid handover time between staff at shift change over times. This ensures ample time to share relevant information between staff.

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.

Staff were knowledgeable about the signs of abuse, and what constituted abuse. Staff were familiar with the reporting process, including to external organisations.

Leaders and managers were prompt to share concerns with external organisations, such as local authority safeguarding teams, and worked with these organisations to ensure people were safeguarded.

The provider understood the Deprivation of Liberty Safeguard (DoLS) process and applied for these were necessary. Staff were knowledgeable about restrictive practice. Previously, there had been inappropriate restrictions in place for the people using the service, the new management team had done extensive work to change this within the service. This included removing unnecessary restrictions, developing staff’s knowledge which in turn augmented people’s liberty and freedom within their home.

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.

Managers had taken steps to embed the involvement of people and encourage positive risk taking since being in post. For example, people were encouraged and supported to attend new and different social and leisure activities, such as trampolining, when they wish to. Risk assessments were completed to ensure people are supported to complete these activities safely.

Where people cannot directly feedback on their experience of new activities, staff utilise the person body language, reactions to the activity and other knowledge of the persons non-verbal communication to gauge their enjoyment and desire to return.

People had risk management plans in place, which detailed known risks for them, and informed staff and other professionals how they should support people with these risks. There was room for improvement to ensure information was person centred for everyone in relation to all risks, but largely, this was the case.

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

There were systems and processes in place, to monitor the environment which included auditing systems. This enabled staff to identify concerns promptly. Staff were knowledgeable on how to escalate concerns to the providers internal maintenance team. The maintenance team were prompt to rectify concerns with the environment, on a priority basis.

Staff had good knowledge of emergency evacuation processes, including in circumstances of fire. The provider conducted regularly checks on fire systems and worked with external organisations as required by law to maintain these. People and staff also participated in regular practice evacuations. Since the arrival of the new managers, there had not been a practice evacuation during the night, however, we were assured this would be completed promptly.

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 systems in place to ensure staff were recruited safely. They utilised systems to monitor training compliance. There were times that staff’s training expired before a refresher could be completed. The provider had a risk management plan in place for this, to ensure there were some staff present with the correct, up to date training, during each shift.

We found during our assessment, that where staff member’s training had lapsed, they were already booked onto refresher courses in the near future, so we were assured this was actioned quickly when it did occur.

Staff told us that they found the training good, and that it helped them to do their job effectively. Some staff particularly favoured face to face courses. A lot of their training was completed online, which is standard now within the sector.

Staff told us that they felt supported by their managers, supervisions were productive and that managers follow things up when staff raise them. Some staff felt that the heavy promotion of communicating via the provider’s app, meant they weren’t welcome to pick up the phone and call someone directly.

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, however, staff did not always uphold the providers policy and process on good infection control systems.

We found there were systems in place to maintain good hygiene within the home. This included within the environment, and the encouragement of people’s personal hygiene.

There were auditing systems in place which enabled staff and leaders to identify concerns promptly. Staff were aware of their roles and responsibilities to prevent infection, including proper processes for donning and doffing Personal Protective Equipment (PPE) such as gloves and aprons.

However, we did not always observe this in practice, and observed poor use of PPE, which had been worn during someone’s personal care tasks, also being used within communal areas of the home. This was raised with managers, and we were assured this had been addressed with staff members. We were not assured that this was not regular practice amongst the staff team, and a larger culture change needed to be embedded.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff followed the providers policies and processes in relation to medication, which included the correct storage, documentation, disposal and oversight systems.

Staff and managers completed audits of medicines, which included checking stock, expiry dates and quality of packaging to ensure medicines weren’t spoiled. Staff checked the temperature of storage areas daily and managers had oversight of these checks.

Documentation was completed clearly and coherently. Staff were trained appropriately and had their competency assessed by their manager prior to administering medicines to people. Competency assessments were completed every 6 months, to check that staff’s knowledge and capability to complete the task was still satisfactory and in line with best practice guidance.