DCA Alderwood

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

We found improvements were required in reducing restrictions people experienced. These had not always been authorised legally and it was not clear that the least restrictive options had been considered nor people’s views fully taken into account. There was limited evidence that people and their families were involved in plans to keep people safe from risks and these were not available in accessible formats. Staff training compliance was improving but further work was needed in this area. Recruitment practices needed improving. However, we saw that medicines were managed safely and effective infection control practices were being used.

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.

Most people’s relatives felt there was a positive learning culture in the service and lessons were learnt from any incidents. They told us staff had learnt when to give the person using the service space. One relative told us, “I don’t feel I am updated regularly on what has happened.” This means that the Duty of Candour was not always followed and people's relatives could not see how the service improved as a result of incidents.

Staff told us they learnt from any incidents that occurred. However, it was not always clear they were recognising all incidents as such. They told us that some people had not had any incidents when recordings suggested there had been several for the person they supported. One staff member told us “There has been an incident before where a staff member was suspended while an investigation was done.”

Partners did not provide specific feedback in this area at the time of the assessment. Prior to the assessment commissioning partners had been working closely with the service to improve care provided to one person. They felt lessons were not always taken on board. Since this time there had been a change in management and improvements were underway, although not yet fully embedded.

We saw from minutes of meetings with staff, incidents and safeguarding issues were openly discussed and lessons shared. For example, consideration would be given around the compatibility of people living within the same house. A Service Pen profile had been created to assist in identifying what personality would make a good relationship within homes with more than one person. This needed to be embedded before we could fully assess the impact and effectiveness. There was limited evidence that staff always recognised events as incidents and therefore not all opportunities to learn and improve the service were being seen as such.

People’s relatives told us their relative was appropriately supported when moving between services.

Staff told us they had access to enough information to enable them to support people safely. This was available to them both in paper format and electronically. They told us new members of staff had the opportunity to read through people’s profiles before providing support.

Partners did not provide any specific feedback in this area.

Arrangements were being made for several people to move to different services. There was limited evidence that plans were in place from the service to support them in preparing for this.  Each person had a Hospital Passport which was detailed and enabled other health professionals to understand and support the person in the best way possible. This minimised the stress and anxiety the person may have experienced. The provider worked alongside other agencies whenever possible if people were moving to another placement. This ensured a smooth transition and supported the person positively through change.

People’s relatives told us they felt the service kept their relatives safe. One person told us physical restraint of their relative had been reduced. Another said, “They have enough staff that are familiar with [relative] and know how to support [them].” They told us that staff are able to support people to prevent situations escalating dangerously.

Staff did not always fully understand restrictive practice. When asked whether people had restrictions in place, they told us they didn’t despite high staffing ratios and one person having limits on access to their mobile phone. Staff told us they had Safeguarding training that was refreshed regularly. They knew how to report any concerns they had.

People and staff were aware of any assessed risks and the plan in place to mitigate the risk. For example, sharp objects such as knives were secured so people only had access to them when supervised. One person told us they used a knife when cooking with staff.

Where Best Interest decisions were made for people there was limited evidence that the least restrictive options had been considered. For example, one person had a four to one staffing ratio during the day and when accessing the community. There was a Restriction Reduction Plan in place. The reasons for this level of staff were unclear and we saw no evidence of the plan being reviewed or aims for reduction. There was limited evidence of what restrictions were being used in practice. We saw records which said a person needed four staff to support for medical appts and staff sat either side of them holding their hands. The manager told us the person did not have any physical restrictions in place. We saw no evidence of trying to find less restrictive ways to meet goals, and inconsistent information of the need for the restrictions in place for people. We were not assured that best practice guidelines had been followed when making decisions in people’s best interests. Some mental capacity assessments, and best interest decisions required improvements to ensure people's views were included, and that the least restrictive options were being considered. The provider was aware of the need for staff to understand and practice safeguarding principles. We saw evidence of improved staff training, and discussions in staff meetings. Staff were advised how to raise safeguarding concerns internally, but not who they could contact externally e.g. The Local Authority or CQC. We were given inconsistent information about the number of incidents across the service. It was not clear that external bodies such as CQC or the Local Authority had been made aware of all incidents. There was no evidence of incident analysis to see if people’s distress could have been avoided or reduced. For example there were 29 incidents reviewed where 26 were recorded as having an unknown cause. This meant people were at risk of not being protected from abuse or improper treatment.

One person’s relative told us they felt the person using the service was “restricted by staff’s lack of specialist knowledge and support as they are more risk adverse.” People’s relatives told us restrictions had been agreed legally but this was not the case for all restrictions being used in practice. People’s relatives told us the person using the service was able to make day-to-day decisions about what they wanted to do but in some cases the activities they did were standardised across the service and were not tailored to individual’s interests.

Staff told us they support people to make decisions about their day-to-day activities. Options are provided to support this. There were risk assessments in place to manage known risks.

People’s homes were clear of any objects which may cause them harm. Houses were clean but some were in need of some refurbishment. People were responsible for their own areas of any multi- occupational dwellings. Some consideration had been given to how the environment supported people’s sensory needs. For example, one person’s home was kept clear from visual clutter to reduce the likelihood of overstimulation by the environment.

Risks to people had been assessed and there were plans in place to mitigate the risk identified. However, there was limited evidence that people or their families had been involved in risk assessments. For example, where people may put themselves or other people at risk staff had been specifically identified to support the person. Although this was kept under review due to changes in the management of the service reviews had been delayed which meant people had restrictions in place potentially longer than they needed. The new manager was in the process of addressing this.

People’s relatives told us the environment was safe, but people would benefit from access to sensory equipment. It was unclear how much input people had in the décor of their homes meaning some properties were more homely than others.

Staff told us they have access to all the equipment they needed. Sharp tools were kept safely in a locked cupboard. One staff member told us the service would benefit from equipment to safely monitor people for potential epileptic seizures. In the absence of this equipment overnight 15 minute checks were being carried out for one person. This could cause disturbed sleep and potentially increase the risk of seizures. The 15 minute checks were also intrusive and not the least restrictive way of managing the risk for the person. In the absence of monitoring equipment, these checks had been agreed by a doctor and the wider multi-disciplinary team.

People’s homes were clear of any objects which may cause them harm. Houses were clean but some were in need of some refurbishment. People were responsible for their own areas of any multi- occupational dwellings. Some consideration had been given to how the environment supported people’s sensory needs. For example one person’s home was kept clear from visual clutter to reduce the likelihood of overstimulation by the environment.

There was limited evidence that the service had considered what environment people needed before accepting them into the service. For example, one person would only wash in a bath but the service had accepted them to a property that only had a shower. Systems were in place to ensure people were kept safe from any risk of fire and poor water quality. Although as this was a supported living service the responsibility for the environment was the landlord. The provider had checks in place which they would use if the accommodation were a care home.

People’s relatives told us staffing was not always effective. On relative said “Some staff seem better than others.” Another relative told us they felt staff did not have the appropriate specialist knowledge to keep people safe and were being overly restrictive as a result.

Staff told us there were enough staff to meet people’s needs. They received training and most felt this equipped them with the right knowledge and skills to support people safely. One staff member told us “I feel like some of the other staff could do with more training, particularly around epilepsy.”

We saw staff knew the people they supported well and could respond to their individual needs. However, we did have some concerns that the number of staff supporting one person was restrictive and some of the reasoning for the level of staffing was not consistent with good practice guidance. There were plans in place to reduce the level of staffing people received and in the case of one person this had been effective. However, for another person the provider could not demonstrate how this plan intended to reduce staffing levels and there had not been any reduction in this.

We viewed the training matrix for the service. Compliance with mandatory training was low. One example of this was only 33% of staff were compliant with Diabetes awareness training in a home with a resident who was diabetic. A training risk management plan was in place which showed improvements, but there were inconsistent expectations of the standards required for compliance across the training program. We were not assured that mandatory or competency-based training was currently sufficient to keep people safe. There were enough staff to meet peoples needs which was confirmed with staff rotas. We saw evidence of the manager understanding the effect on the service and people being supported if staff worked longer hours than they should, and the importance of safe rotas. The provider did not always operate safe recruitment processes. For example, in the four staff files reviewed there were unclear work histories, interview processes not followed, forms unsigned and undated. It was unclear which member of staff the file related to. An example of this was one file contained 3 different named staff. Previous training verifications had not been carried out. Pre-employment references were missing or had sparse or no information and there was no evidence of further investigations into this. A risk assessment was in place to enable a staff member to begin work without the correct recruitment processes in place. Staff supervision was not routinely taking place. We reviewed a supervision spreadsheet which was not updated with correct staff details, and not all staff supervisions had been completed and reviewed within the timescales. This meant we could not be assured that staff were being supported at work, given the opportunity to highlight any concerns, and develop in their roles. All staff reviewed had Disclosure and Barring service (DBS) checks completed. We saw evidence that the provider was aware of the visa restrictions for staff who had them.

No relatives spoken to raised any concerns about infection prevention and control practices. One relative said the environment was spotless.

Staff did not raise any concerns about IPC practices at the service.

People’s home’s were clean and staff followed safe practices.

Staff were trained in infection prevention and control (IPC) and were provided with relevant protective equipment when required. The service had a suitable policy in place.

People’s relatives told us that people received their medication on time.

Staff told us they had been trained to administer medicines. They knew what to do if people refused their medicines. Staff told us there were appropriate authorisations in place if people were given their medicines without their knowledge.

People were aware of what medicines they were prescribed and were supported to take their medicines. Best interest decisions had been taken if people lacked the capacity to manage their own medicines.

There was an up-to-date policy in place with guidance for staff to follow. All staff had been trained in the administration of medicines and their competency regularly assessed. Where people had been assessed to need their medicines to be administered covertly this had been agreed appropriately with the GP and other interested parties. In some cases more staff were being used to administer controlled drugs than is required in a community setting.