Archived: Alderwood LLA Ltd Addington Road

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 has changed to 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 12 in relation to people’s safe care and treatment, infection control and safe environment.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Staff did not always identify concerns about safety and did not always investigate and report safety events. Lessons were not always learned to continually identify and embed good practice. Relatives told us they had confidence in the staff and in the registered manager but at times felt frustrated by a lack of action by senior leaders to resolve known issues such as environmental concerns and working practices having a negative impact on their family members. We observed staff supporting people in distress and they did not always follow the positive behaviour plan. Known triggers were not taken into account such as increased noise and visitors not known to the person. Therefore, action was not taken to manage these situations and prevent or reduce stressful situations. There was a delay in completing a risk assessment for a person at risk of serious self- harm. The provider has since taken action and completed this risk assessment. Staff had an understanding of reporting systems and how to contact a senior member of staff regarding safety issues. However, systems and processes for recording, managing and reviewing incidents were not always effective. The recording of incidents was poor. Staff did not always identify the trigger or cause of the person’s distress. Action taken in response to distress were not always in line with the person’s positive behaviour plan or with best practice guidelines. Analyses of incidents did not identify patterns, triggers or identify solutions to reduce further distress. Debriefs were not routinely carried out for the person involved or for staff, so that learning from incidents could be used to reduce further risk and distress. The provider missed opportunities to learn lessons and to change care practices to reduce the risks of incidents reoccurring. This meant people continued to experience distress.

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.

People using the service had lived there for many years so assessment of people’s experience when moving into the service or moving between services was limited. People had access to the healthcare services they required and were supported to attend appointments. For example, people attended annual health check appointments.

Staff followed the advice of healthcare professionals such as dietitians and psychiatrists . A person had recently been supported to receive dental treatment. Staff provided effective support which reduced anxiety and resulted in a positive outcome for the person. The Registered Manager told us they were developing a document known as a ‘grab sheet’ to use if people were admitted to hospital so important information was provided quickly and was accessible.

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. For example, records of self-injurious behaviour resulting in injury were not always maintained or referred to the local authority for investigation and support. However, following a CQC safeguarding referral, staff began to use body maps to record all injuries and provided an example of how they had identified suspected abuse and had effectively followed the provider’s safeguarding policy and made a safeguarding referral. We observed staff supporting a person who was distressed and was hurting themself. Staff did not follow the persons support plan or risk assessment such as use of specialist equipment designed to protect and visual communication cues to encourage the person to stop hurting themselves. However, during our second visit staff did use equipment designed to protect the person. Relatives told us their family members were safe and had confidence in the staff and registered manager. The provider had a safeguarding policy for staff to follow. Staff had training about protecting people from abuse and mostly understood their roles and responsibilities. The provider displayed information for staff about how to contact the local authority safeguarding team and the provider’s safeguarding lead. Staff also had training about positive behaviour support and physical intervention to keep people safe. Where people required a deprivation of liberty (DoLS) to keep them safe, the registered manager had applied for lawful authorisation, and these were in place, or a response was pending.

The provider did not 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. Relatives told us they were informed of any incident. However, a relative had expressed concern regarding the negative affect noise had on their family member and felt the noise levels created by staff and the environment was causing distress. This had not been effectively identified or addressed by the provider and continued to cause the person some distress. Risks in the environment were not always identified or managed such as hot water temperatures and un-restricted windows. Risk assessments were in place for some individual risks. The majority of staff had attended positive behaviour support and physical intervention training However, positive behaviour plans were not always effective or were not always followed. We observed staff supporting a person who was distressed and staff told us this was ‘normal behaviour’ they did not react effectively or endeavour to understand what was the cause of the distress despite obvious risk to the person and to staff. The positive behaviour plan had identified a reduction in staffing may be beneficial to a person during some activities, but this strategy had not been implemented or tried. There was a lack of robust risk mitigation for people who presented with distress. There was a lack of evidence to support how people were involved in discussions and decisions. Key worker meeting records demonstrated staff had continued difficulties engaging with a person or understanding their lived experience. A positive behaviour plan identified interventions staff could use the use but there was no evidence staff had attempted this method in order to engage and communicate effectively. People were supported to take positive risks. However, further progress was required to ensure people could reach their full potential.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Hot water temperatures were tested weekly and recorded by maintenance staff, records showed these temperatures were in excess of safe temperatures as recommended by the Health and Safety Executive. The provider contacted us following our feedback and told us this was a recording error and there was no risk of harm to people by scalding. However, we were not assured the provider had effective oversight of hot water at the service. There were no window restrictors on the windows within second floor accommodation. This does not follow the Health and Safety executive guidance and can risk people falling from a height. Again, the provider took immediate action and fitted appropriate window restrictors when we pointed this out. Fire protection systems were not fully understood by staff. The provider’s fire safety policy instructed staff to check the fire panel, but there was no fire panel at the service. The fire risk assessment completed in May 2023, had not identified the concerns we identified. The physical environment was not well maintained. People’s flats were not decorated or maintained to a suitable standard. Some carpets were worn ripped and stained. There was damage to walls, doors and shower boards. Environmental risk assessments had not been effective.

The provider mostly 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.

There were enough staff on duty to meet people’s needs. Agency staff used were usually known to the service and knew people well. However, on occasions, staff not known to the service were employed and on one occasion this resulted in an incident where a person became distressed.

Staffing numbers required on each shift were calculated based on the dependency needs of each person and on funding arrangements provided by care commissioners. People had two to one staffing ratios during the day. Rotas showed staff were deployed at all times to meet the funding arrangements of all.

Staff were recruited in a safe way. Checks and references were obtained prior to employment being offered so that as far as possible, only staff with the right character, skills and experience were employed.

Staff mostly received the training they required to carry out their roles. The provider maintained a staff training matrix to identify staff training requirements, attendance dates and updates/refresher dates. While staff have had the training, there are multiple occasions where staff have not followed best practice. Therefore, raising concerns about the quality of training.

Staff received ‘supervision’ from their line manager so they could discuss their learning and development needs and any concerns they may have. The Registered Manager told us not all staff had received supervision in line with the provider’s expected frequency (every 4 to 6 weeks). However, sessions were planned to take place for all staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The provider had a policy for staff to follow about infection prevention and control (IPC). Staff had received online IPC training. The IPC policy stated that cleaning schedules should be followed including tasks, frequency, methods and person responsible. However, there was only a basic nightly cleaning record for staff to follow and this record contained gaps for completion. ·There was a lack of clear roles and responsibilities around infection prevention and control. Audits were carried out but had not identified IPC concerns which we found during our site visits.

Some people who used the service took part in cleaning their own flats. One relative we spoke with raised concerns about the cleanliness of their family members flat. There were many areas of the service which were not visibly clean. These included shower trays, hand wash basins, ovens, hobs, an extractor fan and an electric socket. There was mould on some windows and ceilings. Not all staff were dressed ‘bare below the elbows’ and some wore nail varnish, this did not adhere to the providers IPC policy or with best practice guidance for effective IPC.

Staff had training about effective hand washing and had access to personal protective equipment such as gloves and aprons.

The Registered Manager was able to describe what action they would take in the event of any infection outbreak, and this was in line with expected practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning how they would like their medicines to be managed.

Systems and processes to safely administer, record and store medicines including controlled drugs (medicines requiring additional security measures due to their risk of abuse) were mostly in place. Records we checked showed people were having their regular medicines administered safely. However, we saw that excess medicines were stored instead of following provider policy to return surplus medicines to the dispenser. In addition, the monitoring of temperatures in medicines storage rooms was not in place and this can affect the effectiveness of some medicines. Therefore, the provider could not be assured that these medicines continued to be safe in line with safe medicines management guidance.

Staff received regular medicines training and competency checks. Information was available to support staff on how people liked to take their medicines. However, medicines related care plans were not always accurate and contained generic information on why people were on certain medicines. This was not identified in regular medicines audits. Staff mostly had guidance on when people could receive ‘as required medicine’. However, some people required ‘as required’ medicine for times of distress and agitation Which had not always been considered.

While there was no significant use of 'when required' medicines to help people when they became distressed, there were instances where such medicines were not provided despite their potential benefits. Senior management told us that they are were working on enhancing staff support by identifying early warning signs to prevent people from becoming distressed.

People received regular psychiatry reviews and annual health checks to ensure that their medicines were appropriate and safe for them.