Alice House

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• 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 assessed all the quality statements within the key question of safe. We identified 6 breaches of regulations. Medicines were not stored, administered and managed safely. We found significant shortfalls with the system used to manage controlled medicines. A number of incidents involving people had not been reported to the local authority safeguarding team as they are legally required to do. We identified several risks to people which the service had not safely managed. The service had not always safely managed risks relating to infection control. We were not assured staffing levels within the service were safe. We observed and some staff and relatives told us safe staffing levels were not always maintained. Staff were not always recruited safely, we identified shortfalls in recruitment processes.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not able to tell us about their experiences. We spoke to people’s relatives and no concerns were raised about the learning culture within the service. However, we could not be assured relatives were made aware of accidents and incidents that had taken place. We identified many shortfalls where the appropriate action had not been taken, safeguarding concerns were not always raised with the local authority. The necessary steps to safeguard people and prevent recurrence had not been taken. This meant a lost opportunity to learn from incidents and to identify and embed good practice.

We received mixed feedback from staff about the effectiveness of processes in place to record and learn from incidents. One staff member told us they had completed multiple incident forms with details of concerns, but no action was taken by the registered manager. The provider and other staff told us incidents were discussed at handover and during team meetings, however records maintained by the service did not confirm this.

The processes in place to monitor standards and identify, record and learn from incidents were not effective and placed people at risk of harm. We found several examples where incident records had been closed without appropriate actions being taken or recorded. For example, one person who was recently admitted to the service had been involved in multiple incidents where people were harmed. Appropriate timely action had not been taken to learn from each incident and manage the ongoing risk. People’s behavioural triggers were not always documented and analysed to identify trends and patterns. This meant effective support strategies could not be implemented. The provider confirmed actions and learning from incidents was not always well documented.

People were not able to tell us their views. We spoke to people’s relatives and no concerns were raised about safe systems, pathway and transitions. Overall feedback was positive that relatives were contacted when the GP had visited people.

We spoke with the providers who told us admission assessments should be completed before people were admitted to the service. We showed them gaps in people’s care records, where admission assessments were not fully completed. We explained the associated risk where information was not up to date for some people. We asked the staff about how information was shared with them about people’s wellbeing each shift. Some staff told us the senior or the managers gave a brief handover. They confirmed the service did not have a formal process.

Professionals told us they had some concerns about the services willingness to engage with health professionals and at times had experienced resistance to their advice about people’s care.

The service had not always assessed people's care needs before they move to the service. We reviewed some people’s care records to see how people had been assessed prior to their admission. We found evidence of gaps and incomplete assessments. For example, 1 person had been admitted to the service from another care home. There were known risks to them and others, which had not been assessed. Where people had been admitted to the service or discharged, the list of people living at the service had not been updated. This contained information about people who moved from the home. Some people admitted to the service were not on the list. Staff took part in handover meetings during each shift. Although the service had a senior communication book which contained information about the previous shift, the service did not have any formal records to share information about people’s wellbeing. Staff arranged weekly visits for people with the local GP surgery. Staff planned for the weekly visit by adding people’s names to a list however, an explanation was not always provided as to why the person was to be reviewed by the GP.

Relatives told us they felt their family member was safe living at the service and 1 relative said, “It feels a safe place for mum she is enriched there. Alice House is big enough to not feel hemmed in.” Another relative told us, “Mum is safe and well looked after. She is ok we have our ups and downs about bits and bobs little niggles.” As previously mentioned, during the assessment we observed an incident where a person came to harm from another person using the service. Although the person harmed was not able to communicate verbally, we observed their discomfort and distress. We asked a staff member to check on the person and support the other person away for safety. We informed the provider and the local authority safeguarding team.

Staff confirmed they had access to safeguarding procedures and had received training. We received mixed feedback from staff about reporting safeguarding concerns. One staff member said, “We record the incident online, we send to the manager, we try and keep people safe." Another staff member told us, “I have reported my concerns to the registered manager, but they do not always listen and take action.” We spoke to the provider about our concerns. They told us there had been a lack of oversight of monitoring safeguarding.

We observed 1 person had bruising to their face and an injury to their arm. A staff member told us the person had fallen. On checking the person’s care records, we found the service had not submitted an incident report or completed a body map to record the person's injuries after the fall. The provider told us staff should have completed a body map. Staff had not reported the injuries to the local authority safeguarding team as they are required to do.

We were not assured people were consistently kept safe, from the potential risk of harm. Systems and processes to make sure people were protected from abuse and neglect were not effective or consistently used. We reviewed people’s individual electronic records and identified a significant number of safeguarding incidents had not been referred to the local authority safeguarding team. Multiple incident records had been closed without sufficient detail, further investigation or actions being recorded. For example, when a person’s behaviour had escalated, the staff had recorded the person had hurt other people. It was not clear who the other people were and if any injuries had occurred. One person had fallen and had obvious injuries and bruising. We found examples where staff had not used a body map to record where the person had been injured. This meant staff were not able to monitor the healing process and the size of the bruising/skin tears. A body map is used to pinpoint and record any visible injuries or marks of concern on a person’s body. We spent time with the provider and operations manager and showed them the concerns we had found. They reassured us, they would review all incident reports for people and refer retrospectively to the local authority safeguarding team and the Care Quality Commission. The Mental Capacity Act 2005 provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The service was working within the principles of the Mental Capacity Act and if needed. The service had the required legal authorisations to deprive a person of their liberty.

People were not able to tell us if they felt their risks were managed. We received positive feedback from relatives about how risks were managed in relation to their family member. One relative told us, “Staff record everything”, for example when asked “what mum has had to eat, they weigh people regularly.” Another relative told us, “The staff keep us updated on changes such as meds, illness or whether there has been an incident.”

We spoke to the staff about how risks were manged in the service. They told us, “I check the care plan. One person for example has diabetes and we put sweeteners in her tea.” and “We are working on risk assessments, some new residents we haven’t finished. We are trying to find out more information." We received mixed feedback from the staff whether care records contained sufficient information to support people safely. We were told the staff were working on improving people’s care plans. The staff told us some people’s care plans had not yet been completed, this information was consistent with our findings. This meant the staff did not always have clear guidance on how to care for some people.

We observed environmental risks were not always safely managed. For example, within the communal lounge we observed people had unsupervised access to an iron and an ironing board which had been left unattended. The iron was not locked away when not in use. Although people had risk assessments to use the iron with supervision, staff had not fully assessed and mitigated this risk for people at the service. People were living in the service with a diagnosis of dementia and some objects had been used during incidents and altercations with people. We were not assured that the service had taken sufficient action to reduce these risks and prevent these incidents from happening again.

We were not assured people’s risks were always sufficiently assessed and mitigated, with clear guidance for staff to follow. Risks relating to people’s nutrition and weight loss were not being safely managed. We found some people had lost a significant amount of weight within a short period of time. Although staff were weighing people regularly, staff did not always document what action they had taken and what medical advice had been sought . Risk assessments around managing people’s weight loss were not up to date. Risks relating to people’s health conditions were not always well managed. For example, some people had a diagnosis of diabetes however, we found people did not have diabetes care plans to advise staff how the person’s medical condition was being managed. This included who was monitoring their glucose levels, how their diabetes affected them and how associated risks were managed. One person had been identified as having difficulty chewing. The service did not have any guidance available to support them or evidence that a speech and language referral had been made. This person was potentially at risk of choking. Risk assessments in place relating to people’s behaviours, were not always sufficiently detailed. Some people had been involved in altercations with other people using the service, and one person regularly displayed disinhibited sexualised behaviours, which posed a risk to others. We found insufficient information was recorded regarding how staff were to manage and de-escalate people’s behaviours. This had placed people at increased risk of harm.

People were not able to tell us their views of the environment. We spoke to people’s relatives and no concerns were raised. One relative said, “Mum likes to potter and she has the space to do that, she gets involved in ironing, washing up and often packs up her belongings.”

We spoke to the providers about fire safety at the service. They told us that no fire drills had been carried out with staff in the last 12 months. A fire drill is used to test a service’s fire procedures with the staff. We reported our concerns to the local fire authority.

We observed people moving freely around the downstairs area. The outside space was secure for people to use. We spent time looking around the environment of the service. We found radiators in bathrooms, where people were exposed to hot water pipes. The radiators had not been safely covered to protect people from the risk of the exposed hot pipes. We showed the provider and shared our concerns. They took these bathrooms out of use, until further action was taken to ensure people’s safety. One person had used sticks and tools during incidents of distressed behaviour. We checked, and found these items were readily available in the garden. We showed the provider the items we found, and they took action to store them securely.

Staff did not always sufficiently assess risks within the environment. The service had environmental risk assessments however, staff had not fully assessed and mitigated the risk to people of hot pipes and radiators in bathrooms. Staff had not fully assessed or mitigated risks to people to create a safe environment for people living with dementia. As we have mentioned above. As we have mentioned above, sticks and tools were available within the environment for people to use and an iron was left unattended. We received evidence the service had the necessary safety checks and certificates. This included checks of the fire equipment, gas and electrical safety. In the manager's office was a fire grab bag to be used in the event of an emergency. The bag contained a log of people living at the service. However, this was not up to date. One person had been recently admitted to the service, but their name was missing from the list, along with their personal emergency evacuation plan. This is a document that outlines how someone will be evacuated during an emergency, if they have difficulty escaping a building or responding to a fire alarm. Another person had been discharged from the service, but their name was still listed along with their personal emergency evacuation plan. The fire log contained conflicting information as it recorded 2 people were independent and then dependent. The level of support people required to evacuate the building in the event of an emergency was not accurate.This posed a risk to people as they may not receive the level of support they need to leave the building during an emergency.

The service should have enough staff with a suitable skill mix to make sure people receive consistently safe, good quality care. We received mixed feedback from relatives about staffing levels at the service. Comments included, “Staff are always busy. There is usually 2 or 3 staff around, they are not overstaffed for sure.” Another relative told us, “Not enough staff, never seems enough in ratio to people with usually 2 or 3 staff. Staff are generally all quite nice and seem pretty good but can be busy.” Relatives told us they felt staff were competent in their roles.

Two staff told us that 1 person had been assessed for needing 2 staff to hoist them safely. However, they told us, that at times due to staffing shortages, the person was hoisted by 1 member of staff. The provider told us due to staff sickness that the service was not always able to find cover, this meant usual staffing numbers were not maintained. The provider was not using agency staff to cover the staffing shortages. This posed a risk as the people that lived at the home had dementia and required the constant supervision and care from the staff throughout the day and night. Some people did not always receive the level of care and support that they required. Some people's behaviours had at times caused them and others distress.

We observed staffing levels were not sufficient to ensure peoples safety and needs were met. During the assessment we spent time observing the interactions between staff and people. At points we observed the environment was chaotic, and people waited 45 minutes for their lunch to be served. During lunch, we observed 1 staff member supporting 11 people, some with complex needs. We observed heightened levels of agitation and disagreements between people. We observed an incident where a person came to harm from another person using the service. Management had informed staff not to leave the person unsupported due to the risk, however there was insufficient staff available to ensure this was maintained at all times. We reported our concerns to the provider and the local authority safeguarding team. Despite these concerns, we also observed some positive interactions between staff and people. The staff appeared attentive and caring towards people.

We asked the provider how they determined staffing levels at the service. The service had calculated each person’s dependency using two different tools, but an overall assessment of safe staffing levels was not in place. The provider had not sufficiently reviewed people’s dependency level, when their needs, and behaviour had changed. For example, one person was deemed low dependency; however, records showed they had been involved in regular altercations and their behaviours and needs were unpredictable. We reported are concerns to the provider about staffing levels. We gave feedback regarding our observations and the incidents we had observed. They told us they were no longer able to manage the needs of 2 people. We asked the provider for assurances in relation to how the risk would be immediately managed. They requested staff from an agency to provide 1 to 1 care for a person. We reviewed a selection of staffing rota’s which confirmed staffing levels were not being regularly maintained. The operations director informed us they had taken action when a new staff member was found to be working without a completed Disclosure and Barring Service (DBS) check. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Although this staff member had since returned to work following the completion of their DBS check, records showed references had not been obtained from their previous employment in health and social care. The service had not completed a risk assessment to manage the risk. Other staff records we reviewed revealed further gaps in recruitment processes. We found examples, where only 1 employment reference had been obtained for staff and application forms did not include a full employment history. Interview and induction records were not present on all staff files we reviewed.

People were not able to tell us if they felt safe infection control practices were followed. We spoke to people’s relatives and no concerns were raised. One relative said, “The home was always clean and no smells.”

We received mixed feedback from staff about the management of infection control. Some staff told us personal protection equipment, also known as PPE was not always available when they required it, for example gloves and aprons. One staff member told us they had completed personal care without PPE, as this was not available.

We observed poor practice in relation to the management of laundry and use of PPE. We found people’s used bedding temporarily stored in containers without lids in communal bathrooms. Whilst there was a good supply of pads and PPE within locked storage, there was a minimal supply within the service where it could be easily accessed by the staff. We observed 1 staff member administering cream to a person’s foot without wearing gloves. This placed the person and staff member at risk of harm due to cross contamination.

We were not assured procedures in respect of infection control practices were effective. As we have mentioned above, we found a lack of PPE was available and used laundry was not stored safely. We reviewed cleaning schedules and found these were in place and completed by the staff.

People were not able to tell us if they felt their medicines were administered safely. We spoke to people’s relatives and no concerns were raised about the administration of medicines.

Staff told us they received training about the safe management and administration of medicines. The records we checked corroborated this. Staff told us they had their competency assessed following completion of initial medicines training; however, we found additional annual competency assessments did not include direct observation of staff administering medicines. The staff told us they would report any concerns regarding medicines errors to the provider. They were not aware of how to record medicines errors formally, other than within people’s care notes. The provider confirmed the service did not have a robust process to record medicine errors.

Medicines were not stored and disposed of safely. We found some discontinued controlled medicines insecurely stored in an office drawer along with office supplies. The provider had a controlled medicines cabinet, and it was not clear why the medicines were not stored safely within the cabinet. The discontinued controlled medicines had not been safely disposed of. We found no evidence within the disposal of drugs book that these medicines were listed. The provider and registered manager were unable to tell us why the medicines were in the office drawer. We found a member of staff in possession of a controlled drug which they told us was prescribed to them. However, on further investigation, we found these were prescribed to a deceased resident. Follow up action was taken by the CQC with other agencies contacted, to ensure people were safe. Pain patches are used to manage some people’s pain. The patches were not being rotated on people’s bodies and the location of the patch was not changed each time. No body maps were in place to show staff where on a person’s body, the patch was last applied. A homely remedies box of medicines was in place. A homely remedy is a medicine used to treat minor ailments. They are purchased over the counter and not prescribed. They are kept as stock in a care home to give people access to medicines such as mild pain relief, treatment for coughs or indigestion. The box however, contained medicines prescribed and belonging to current people living at the service, this included paracetamol and senna. Medicines prescribed for people, should only be for their use only. We checked the fridge used to store some medicines. The fridge temperature was not always within a safe range between 2 and 8 degrees. An example was from 10 July 2024 there were only 4 dates when the temperature was recorded as being within a safe range. The operations manager confirmed the service did not have a system for recording and monitoring medicines errors.