Alderlea 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 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 in relation to people’s safe care and treatment; the ways people’s medicines were managed, and safe staffing of the service.

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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The provider had processes in place to learn from incidents and accidents; however, these were not always effective in practice. There were systems for reviewing incidents, identifying trends and sharing learning with staff. However, these were being reviewed individually and there was no process in place to identify themes or trends for the whole service. Auditing processes had not been consistently completed, limiting the provider’s ability to identify and address risks promptly.

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. Care plans did not always provide staff with sufficient information to deliver safe care. We found inconsistencies, including unclear information within mental capacity assessments, the ability of a person to safely use a call bell, and a lack of clear moving and handling guidance for staff to follow. Some people with wounds did not have wound care plans in place. We found falls had not been escalated appropriately or managed in line with the provider's policies. This included people who were prescribed blood-thinning medication, which can increase the risk of serious injury following a fall. Records did not demonstrate that appropriate action had been taken or that medical advice had been sought promptly when falls occurred, placing people at increased risk of harm. Relatives described positive transitions into the service. One relative told us, “[Name] originally went in for one week's respite and stayed because they couldn't remember where they lived before”.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately. The provider made appropriate applications for Deprivation of Liberty Safeguards. Although many staff had not completed safeguarding training, people and their relatives told us they felt safe. Staff demonstrated an understanding of how to raise concerns, and external professionals described them as responsive when concerns about people's wellbeing were identified. Improvements were needed to ensure all staff completed safeguarding training in line with the mandatory training requirements. A relative said, “I feel it's 100% safe there”.

The provider did not always 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. The provider involved people and relatives in decisions about managing risk and the manager described working with families and professionals when risks were identified. Relatives gave examples of risk management improving following incidents, including referral to external agencies for support for people at risk of falls. However, risk assessments were not always detailed, personalised or up to date. We discussed this with the manager and provider, who planned to review the information in people’s risk assessments.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The environment was clean, welcoming and contained equipment to support people safely. However, we identified concerns relating to fire safety. The provider could not evidence that fire drills and safety checks were being completed, and some staff could not recall being involved in a fire drill. We also found environmental risks including items stored on top of wardrobes, posing a risk of items falling from height, and wardrobes which were not secured to walls, posing a risk of injury to people. Although some issues were addressed promptly during the inspection, these findings demonstrated the provider was not always identifying and managing environmental risks effectively.

The provider did not 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 work together well to provide safe care that met people’s individual needs. Recruitment records contained the required information, and staff were described as friendly, polite and supportive. However, training records did not provide assurance that staff had the skills and knowledge required, with significant gaps identified in mandatory training such as infection control, and nutrition and hydration. A staff member also described receiving limited induction support when they started in post. People and their relatives felt there were enough staff available and spoke positively about the consistency of staffing. A relative said, “There have always been enough staff whenever I've visited”.

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. The home appeared clean and staff understood the use of personal protective equipment. However, infection control audits had not been completed consistently, and we found concerns including bowls on floors in sluice and bathroom areas, and a lack of kitchen cleaning records. The manager acted during the assessment to put these in place.

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.

Medicines were administered with respect, and people’s preferences were acknowledged. However, we found concerns with medicines management and record keeping. Medicines records were not always accurate, and staff could not demonstrate a clear audit trail for the receipt, administration and disposal of medicines. This meant medicines errors, missed doses or unauthorised administration may not be identified. We were not assured that controlled drugs and other high-risk medicines were being managed safely, as newly delivered stock from the pharmacy had not been accounted for when we checked. There was no evidence that controlled drugs audits had been completed by the manager. Although we found no concerns with medicines administration in practice, oversight arrangements were not robust. The provider advised audits of controlled drugs would be completed after our feedback. A person who lacked capacity to consent to taking their medicines, was refusing medicines. Staff were administering medicines crushed in food in line with a GP's letter and were using the least restrictive approach. Staff were aware of the arrangement, and it appeared appropriate for the person's needs. However, the required documentation to support and authorise this practice was not in place. The manager took steps to ensure this was obtained from the relevant professionals. Medicines storage was not being monitored effectively. Records showed that the temperatures of the medicines fridge and medicines room were not consistently checked. Without effective temperature monitoring, medicines may be exposed to conditions outside the manufacturer's recommended range, which could affect their quality, safety and effectiveness. This meant people could be at risk of receiving medicines that may not work as intended.