Alderwood L.L.A. Limited - Irchester 2

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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

During our assessment of this key question, we found concerns in how risks in relation to people’s individual needs were assessed, managed and mitigated. This resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Whilst procedures were in place to review and learn from incidents, procedures were not sufficiently robust. The staff rota confirmed overall people received their commissioned hours. Agency staff were used when required to cover staff shortfalls, however, we were not sufficiently assured they were fully trained in accredited behavioural strategies and crisis management the provider used. Medicines management needed improvement, this included how medicines were stored and administered. Protocols for medicines prescribed to be administered when required were not sufficiently detailed. Staff understood their roles and responsibilities in protecting people from abuse and the risk of harm. Safeguarding concerns had been raised with the relevant external agencies when required.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they were made aware of incidents that involved their family member. A relative said, "If there was an incident, they [staff] would inform us straightaway." People told us they were happy with their care and support and felt staff supported them well and kept them safe. They knew who the registered manager was and felt confident they could talk to them about any concerns they had. However, the provider had failed to follow their incident management procedure in supporting people to be involved in debrief meetings following an incident. We were therefore not sufficiently assured people received opportunities to be involved in how safety concerns were managed safely and effectively.

Staff told us there was a positive learning culture. Staff reported how the registered manager shared information and learning following incidents. A staff member said, “Yes, we talk about things together we share information.” Another staff member said, “Yes, I'm confident all staff are open and honest, the manager has an open door policy. We have a communication book, handover and staff meetings when we discuss incidents and any learning or any changes to people's needs.” However, records showed, and the registered manager confirmed, there was a lack of formal opportunities for staff to participate in debrief meetings following incidents to discuss actions required to reduce reoccurrence.

There was some evidence of organisational learning from previous CQC assessments of other services within the provider’s organisation. For example, blanket restrictions that had been in place such as people having restrictive access to the kitchen and locked doors to the external garden had been removed prior to this assessment. However, the systems and processes that recorded, monitored and reviewed incidents were not sufficiently robust to consistently identify learning opportunities. For example, incident records completed by staff lacked detail to enable the management team to effectively review and complete a functional analysis which meant learning opportunities to review and reduce risks to people were missed. We also identified how staff had not correctly assessed the level of severity for a critical incident and this had not been identified by the management team responsible for review and oversight of incidents. The provider’s incident management procedures expected following critical incidents, de-brief meetings should occur. Incident records confirmed there had been two critical incidents in March and July 2024 and a critical de-brief meeting had not occurred. Whilst we reviewed a staff de-brief record dated March 2024 where a staff member was injured during the incident, the record showed limited discussion and learning and there was no involvement with other staff on duty or the wider team. There was no action to reduce reoccurrence. The registered manager told us how they had completed some discussions with staff and the person following incidents, however they confirmed this was not always recorded and did not happen as routine. Staff meeting records dated 2024 also showed there had been no staff team approach to learning opportunities following incidents. This demonstrates there had been missed opportunities for learning, due to shortfalls in the systems and processes that recorded, reviewed and analysed incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us their loved one was safely cared for. A relative said, "[Name] is safe at the service, they've been there for some time now and considers it their home.” Another relative said, "We went all over the country to find [name] the right place and this is the right place." No concerns were raised about Deprivation of Liberty Safeguards. People told us they felt safe living at the service. No concerns were raised about the care and support they received from staff. Two people told us how they got on well with each other, and how they sometimes participated in external community activities together. People told us they would speak with the registered manager if they had any concerns about safety. However, we were not sufficiently assured people were fully protected as far as possible from the risk of avoidable harm, due to shortfalls identified in how known risks had been assessed and managed.

Staff understood their role and responsibilities in keeping people safe from harm and abuse. This included recognising possible abuse and how to escalate concerns. A staff member said, “If I saw something that's a concern I would report, such as a staff member raising a hand to people, not following care plans guidance, being disrespectful or bullying, I would record and report to the manager. I would also consider any changes to people's behaviours, such as unexplained bruising, refusing to come out the room, shying away from staff.” Staff felt confident if they raised a safeguarding concern the registered manager would act upon it. Staff were aware of the Deprivation of Liberty Safeguards (DoLS). A staff member said, “This is a way of keeping people safe legally. Any restrictions on a person have to be included in a DoLS.” Staff confirmed they had received safeguarding and DoLS training and had access to the provider’s safeguarding and DoLS policy and procedure. However, we were not fully assured staff had been sufficiently supported, in how to manage incidents safely to protect people from avoidable harm.

Observations of staff engagement with people was positive. People appeared relaxed in the company of staff and interactions were relaxed, calm and respectful. Staff clearly knew people well including their routines, preferences and what was important to them. Staff picked up on and responded effectively, when people required assistance and or reassurance. People appeared well cared for. Some people experienced self injurious behaviour that could cause injury to themselves. We observed no visible injuries, staff had recently received additional training in wound management in response to a person’s self injurious behaviours and this had a positive outcome for the person. Safeguarding information was made available for people, visitors and staff.

The provider had safeguarding, whistle blowing and DoLS policies and procedures. However, we were not fully assured the provider’s safeguarding policy dated June 2024 was sufficiently robust. For example, the policy stated the local authority safeguarding team should be contacted and other relevant statutory bodies immediately, where significant risk had been identified. However, we found no evidence that safeguarding incidents and or allegations had not been reported externally as required. We would expect all safeguarding incidents, allegations and suspicions were immediately reported regardless of the severity of risk. Systems and processes that assessed, reviewed and mitigated risks that could impact people’s safety were found to not be sufficiently robust. Incident procedures were not sufficiently safe and meant people were at greater risk of experiencing avoidable harm. The provider’s training matrix showed staff received ongoing safeguarding and DoLS training. The registered manager monitored DoLS application submissions and authorisations granted. We noted people did not have a care plan that detailed their DoLS authorisations. This is important information that staff needed to be aware of. The registered manager agreed to complete one. We did see a staff meeting record dated 2024 that confirmed a staff discussion about DoLS, that included why people had these. The provider met their responsibilities under the duty of candour. Care records and correspondence confirmed the registered manager was open and transparent with relatives about incidents and accidents.

Relatives were confident staff were responsive and supportive in the management of risks, and they were consulted and involved in decisions about how risks were managed. A relative told us how staff were working with external professionals to support their family member with an increase in distressed behaviour. They said, “We've had a lot of teams meetings with the mental health team (intensive support team) and family. It's a difficult situation with [name]. Staff are finding ways to deal with it. The mental health team have given training for staff and the feedback is that they [staff] are very receptive.” However, there was a lack of evidence to support how people were involved in discussions and decisions about potential risks and safety. We were therefore not sufficiently assured risks about care and support was person centred.

Staff told us about the training and strategies they used to understand and support people at times of distressed behaviour. Staff told us people’s care plans provided information and guidance of how to manage and mitigate risks. Whilst some staff felt confident that they were equipped with the right training, guidance and resources to support people safely at times of crisis, other staff felt less confident. Concerns were raised by some staff of their ability to safely and effectively support a person when at crisis due to the level of risk the person could present with. We shared this feedback with the management team to follow up.

People were being supported by staff as per their commissioned hours. People were relaxed within the company of staff and engaged in activities, staff followed people's care plan guidance and communication needs.

The provider’s systems and processes that assessed people’s individual risks in relation to their safety and wellbeing and the actions required to mitigate risks, were not sufficiently robust. For example, a person’s incident records for March and July 2024, described the person’s distressed behaviours during a period of crisis. However, the person’s positive behavioural guidelines that informed staff of the distressed behaviours the person could present with during crisis, did not accurately reflect the potential level of severity and risk to the person and others that had been displayed in previous incidents. Whilst staff were provided with guidance of the strategies to support the person at crisis, there was no risk assessment to determine the crisis prevention strategies were safe and effective to manage this level of risk. The registered manager and management team responsible for the review and oversight of risk management, had failed to follow their own policies and procedures in how critical incidents should be safely managed. We were not sufficiently assured risks were assessed, reviewed and mitigated safely. The provider had failed to ensure all reasonable and practical actions had been taken to mitigate risks. This put people and staff at increased risk of harm.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us they were confident there were sufficient staff available, and they had no concerns that their family member did not receive the staff support they had been assessed as requiring. Relatives also raised no concerns about staff competency. A relative said, "There’s always enough staff, [name] is 2 to 1 funded and we have no complaints at all.” People told us they liked the staff team and named different staff, including their keyworker (a named staff member with additional responsibility). People knew who the registered manager was and confirmed they saw them regularly, and how the registered manager made themselves available when requested. However, staff records demonstrated some shortfalls in how they were supported and this put people at increased risk of not receiving safe and effective care and support.

Staff told us there were sufficient staff employed to meet people’s individual needs. They advised that staff worked extra shifts to cover any staff shortfalls or relief staff were used and agency staff as a last resort. A staff member told us how on occasions staffing had reduced by one staff due to not being able to get a short notice staff cover, however they said this was not frequent and raised no concerns about safety. Staff confirmed they had a face to face interview when they started and relevant employment checks were completed such as employment history, DBS (disclosure and barring service – criminal records) and reference checks. Staff were positive about their induction, ongoing training and support they received. A staff member said, “I had a face to face interview, this included a number of questions. I had my references and DBS checks completed before I commenced work, I attended at week induction at head office this was 9 till 5 and was very detailed. However the real learning is on the job. I completed shadow shifts where I was supernumerary. I've had meetings with the registered manager to talk about my work and development, to see how I'm getting on, I've had a couple of meetings, and I find them very helpful." However, the provider’s systems and processes in how staff were supported with their work including training and competency showed some shortfalls. We were therefore not sufficiently assured staff were fully supported in their role.

We observed there were sufficient staff available and this was in line with people’s assessed needs and commissioned hours. People appeared relaxed within the company of staff. The atmosphere was relaxed and calm and staff were organised and attentive and responsive to people’s individual needs. Staff we observed followed people's care plan guidance and communication needs. The staff allocation document and rota matched staff who were on duty.

Records showed there had been 10 occasions between August and November 2024 when staffing was less than the hours commissioned to meet people’s needs. Whilst the registered manager told us this had been assessed as safe, it impacted on people’s usual routines and abilities to access the community as they wished. Staff had not received supervision at the frequency the provider expected. The registered manager was aware and had plans in place to address this. Staff observations and competency checks were minimal although improving. Whilst new staff had been recruited, they were still developing their knowledge, skills and experience. Some staff raised concerns about the lack of specific training, support and guidelines of how to safely support a person when at crisis. This put people and staff at increased risk of harm. The staff training matrix showed some gaps in training, but this was known, and actions were in place for staff to complete refresher training within a specific period which we were assured about. Regular agency staff were used as a last resort to cover short notice staff absence. However, from reviewing their agency profile and speaking with the registered manager, we were not sufficiently assured they were fully trained in positive behavioural support and the provider’s preferred accredited training in behaviour management. This meant people were not continuously supported by staff who were sufficiently competent, skilled and experienced.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives were confident medicines were managed safely. A relative said, “They [staff] Keep all the logs for medicines, they are very fastidious about that.” However, we were not assured people were involved in reviewing the level of support they needed and decisions about their medicines.

Staff told us about the training and competency assessments they had completed in the management and administration of medicines. This included STOMP (stopping over medication of people with a learning disability, autism or both). Staff confirmed they had access to the provider’s medicines policy and told us of the actions they would take if they had made a medicines error. Staff told us how people’s medicines were regularly reviewed by the GP and or psychiatrist. However, a review of people’s medicines found shortfalls not identified by staff. We were therefore not sufficiently assured that staff were fully competent in the management of medicines.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. We observed staff giving medicines to people in a caring and person-centred way. Systems were in place to safely administer and store medicines, however the provider’s policy regarding medicines that required refrigeration was not being followed. Records we checked showed people were having their regular medicines administered safely. However, PRN protocols needed to be improved. Staff had completed medicines training and had their competency regularly assessed. Medicines audits were completed; however they did not identify some of the issues found during this inspection. We observed a staff member administering a person’s medicines. However, they did not follow the provider’s medication policy that states for the administration of medicines, ‘Only complete the MAR (medicine administration record) with initials on top of the dot when the person has taken their medicines.’ The staff member had recorded their initial before administering the medicine. For medicines requiring refrigeration, a lockable fridge should be used as per the provider’s policy. We found a domestic fridge was used, the policy therefore was not being followed. PRN (medicines prescribed to be administered as and when required) protocols needed reviewing to be person-centred and have more detailed information to appropriately support staff to administer these medicines safely. Expiry dates on medicines when opened should follow the manufacturer guidance. An incorrect expiry date was seen on an open medicine. We discussed these findings with the registered manager who agreed to make immediate improvements. No person had come to harm.