Aldercar Residential 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. At our last assessment we rated this key question Good. At this assessment the rating changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed safely and safeguarding.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Incidents were not always recorded or escalated appropriately. This meant they were not always being reported to the relevant agencies and therefore the provider was not being open and transparent. There was no effective system in place for the provider to have oversight of incidents, analyse trends, take action or share learning with the staff team. This meant people were at risk of harm from repeated incidents. These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

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.

Whilst we did receive positive feedback from healthcare partners who worked with the service, we did find that transitions were not always carried out safely and the service did not always manage people’s safety effectively.

Preadmission assessments, to ensure the service could safely meet people's needs, were not carried out thoroughly. Staff told us on occasion people were left unaccompanied when they were taken into hospital in an emergency.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

Staff were not up to date with their safeguarding training and did not always identify and escalate safeguarding concerns appropriately. The provider did not follow their own policy on who to inform when potential abuse occurred.

We observed restrictive practice; people were not supported to keep their mobility equipment nearby effectively restricting them to where they were sat.

The provider was not meeting their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS), people did not have the correct assessments in place to ensure they were being supported with care and treatment legally.

These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

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

People told us they did not recall being involved in any care planning or risk assessments, the majority of people did not have documented risk assessments or detailed care plans in place to help staff manage risks. Where people had been identified to be at risk of displaying aggression there was no documented comprehensive guidance on how staff could deescalate and support people to manage this risk.

People were not supported to help manage risks associated with their health and wellbeing effectively.

These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

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

We identified several taps and radiators that presented a scalding risk. Whilst these had been identified during monthly checks, no action had been taken to mitigate the risk. This placed people at the risk of harm from burns or scalding.

People had Personal Emergency Evacuation Plans (PEEPs) in place, however they lacked detailed information on how to support an individual in an emergency and some lacked people’s room numbers.

We found that equipment was not always safely stored and the staff room had been left unlocked on multiple occasions which made confidential information and items that posed a risk, accessible to people.

These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Whilst the provider used a staffing dependency tool based on people’s needs to calculate how many staff were required, we observed people not always receiving timely care due to staff being busy supporting other people.

People told us they felt staff were rushed. A person said, “Staff are under so much pressure if I ask for a cup of hot water I might not get it.” Another said, “I get told off if I use my buzzer too often at night.”

The provider did not always delegate tasks to appropriately competent and experienced staff. At the time of the inspection the majority of staff had not completed their training to ensure they had the skills to support people safely.

Staff were not always recruited safely, we found appropriate checks were not always carried out prior to employment.

These were significant shortfalls placing people at the risk of harm and we have asked the provider to take action, which they have started to immediately.

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.

Due to the service needing refurbishment works, particularly the bathrooms, we found that effective cleaning was not always possible to prevent the risk of infection. The provider had kept 2 unlocked fridges in the dining room, which were accessible to all and contained raw meat, this posed a risk of infection.

There were also concerns over equipment not being regularly clean and food being stored uncovered.

These were significant shortfalls and we have asked the provider to take action, which they have started to immediately.

People told us they felt overall staff did keep the service clean and tidy.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We found prescribed topical creams to not be stored safely and records relating to creams were not being completed accurately. People who were prescribed medicines that were administered via a transdermal patch were not supported with these safely, as records for patch placement were not always completed. Some people received their medicines ‘when required’ (PRN), for these we found there were not associated protocols in place, this meant staff did not have the personalised guidance on when to administer these medicines.

Were people received their medicines covertly, without their knowledge, the correct legal documentation for this administration was not in place. Some people had to have they medicines at specific times, to ensure their effectiveness and safety, however the provider had no effective system in place to confirm people received their medicines as prescribed.

We did observe people receiving their medicines, staff were supportive and patient, they waited until people had taken their medicines and offered pain relief in a discreet way. However the same administration pot was used for all people, which posed a cross contamination and infection risk.

These were significant shortfalls that placed people at risk of harm and we have asked the provider to take action, which they have started to immediately.