Alderwood L.L.A. Limited - Irchester

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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, Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 13, safeguarding of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 18, Safe and effective staffing 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. People at significant risk of harm did not have their needs sufficiently assessed or risk mitigation in place to prevent incidents occurring. Whilst procedures were in place to review and learn from incidents, procedures were not sufficiently robust. The staff rota confirmed overall people did not regularly receive 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. Staff understood their roles and responsibilities in protecting people from abuse and the risk of harm, however significant safeguarding concerns were not always raised with the relevant external agencies when required. Medicines management needed improvement, this included protocols for medicines prescribed to be administered when required were not sufficiently detailed.

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.

Relatives confirmed they were informed if there had been an incident or an accident. One relative told us, “They’d let us know if there was an incident or an accident.” However, one relative told us they had not been told of a significant incident regarding their family member and they were not involved in the learning of such incidents.

The registered manager had started to implement learning from incidents and reflection on staff practice in team meetings and supervisions. However, Staff told us they don’t always have a debrief following incidents or when supporting people who have displayed distress. A staff member told us, “This is sometimes skipped but think this is because the new manager is settling in.” another staff member told us, “I’ve not had any debriefs for anything that I've reported in terms of behaviours”. Staff told us they were unsure if lessons are learnt from incidents and if this is something that is embedded in the service.

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 assessment which meant learning opportunities to review and reduce risks to people were missed. There was a lack of systems and processes to ensure debriefs with staff and people were completed timely and effectively. Examples of debrief meeting records were poorly completed, and did not include a discussion with the wider team on duty at the time of the incident, the person or people supported involved. This meant the provider missed opportunities to ensure lessons learnt, and actions identified were taken and change in care practice was implemented to reduce the risk of incidents reoccurring.

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 felt the overall safety of the service was adequate, However, we were not assured the provider had robust systems in place to manage safeguarding concerns effectively and keep people safe from further harm. A relative told us they were not informed of a significant incident involving their family member and health care professionals raised concerns in relation to a lack of staff reporting and actions taken following the incident.

Staff had completed safeguarding training and were aware of their roles and responsibilities to keep people safe from harm. However, staff did not understand their responsibilities in ensuring all safeguarding concerns are reported and recorded appropriately.

Throughout the inspection we observed staff supporting people with their emotional and behavioural distress. An incident on the 2 December 2024 resulted in an injury to a staff member. This had not been recorded or reported to management. We asked that this was completed, and the registered manager followed this up with the staff members involved.

The provider had policies in place to manage safeguarding incidents safely. However, there was a lack of robust systems and guidance to ensure staff knew who to contact and what actions must be taken in the event of serious safeguarding incidents. Ineffective processes meant safeguarding incidents had not been managed in line with the providers policy. For example, in December 2024 there was a significant safeguarding incident involving a person supported at the service, this was not escalated through the management team. This meant people who were at risk of harm did not receive medical attention in a timely manner or have potential safeguarding incidents reported to the appropriate organisation to protect them safely from further harm. We took enforcement action, and the management team responded to ensure a process was developed for staff to follow and managerial cover was adequate.

Most relatives did not raise concerns regarding risks to people, However, one relative had serious concerns that risks regarding distressed behaviours were not being managed sufficiently to keep their family member safe and prevent harm. We were not assured people’s individual risk mitigations was effective or proportionate to the level of risk presented. This meant people were exposed to harm through ineffective processes and practice.

Some staff lacked knowledge and understanding of a positive behaviour support (PBS) methodology. Staff were unable to tell us what strategies are used to keep people safe though proactive, active and reactive approaches to support people in distress. The provider was in the process of changing their behaviour training methodology at the time of the assessment. Some staff were trained in the new ways of working and some staff were not. The registered manager told us, “I think it could be improved, people supported are at risk of harm and would require more restrictive interventions to keep them safe.”

Communication folders were recorded in people’s care records as being an important part of keeping people safe. We did not observe staff using care planned communication methods with people at any time during our inspection visits despite spending seven hours observing staff supporting people. We observed two people supported by their allocated staff and their communication books were left in other rooms or not accessed or used throughout interactions with people.

The provider’s systems and processes that assessed people’s individual risks in relation to their safety and well-being and the actions required to mitigate risks, were not sufficiently robust. For example, there was a lack of robust risk mitigation for people who presented with distressed behaviours. Crisis intervention risk assessments had not been completed to ensure staff approach was a proportionate response to the risk of harm people presented to themselves and others and each person had the same generic communication folder in place. The communication methods and PECs used within the communication booklets was not individualised for each person. This meant people did not have their preferred method of communication assessed and staff lacked guidance on how to support people with meaningful interactions or effective communicative distraction techniques. We took appropriate enforcement action to ensure people were safe. The management completed full reviews of all people’s PBS and crisis management plans to ensure effective guidance was available for staff teams working directly with people.

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 there was sufficient staffing in the service when they visit the home, However, relatives told us there was a lack of skilled staff to ensure their loved ones could access their planned activities. One relative told us, “There’s a shortage of staff who are able to drive, so that’s restricted their ability to go out during the week. On at least one occasion they weren’t able to go on their regular activity. We find out because we call every evening to check.” And “We were getting the impression they weren’t going out, they acknowledged it had been an issue.” Another relative told us, “[Name] is meant to have swimming every Wednesday and it doesn’t always happen. There’s not enough staff to take them, they’re either non-swimming or non-drivers. It’s happened more recently, quite a few times. There’s nothing offered instead.”

Staff told us at times they had to work short staffed within the service. One staff member told us they had recently had to work alone with a person who required 2 staff. Staff said, “Very rarely do they get agency staff in, the shift leader is not supposed to be allocated to a person, but a lot of the time it’s always 13 and shift leader needs to be allocated. Sometimes we are only working with 10 or 11 staff”. A second staff member told us, “We are sometimes short staffed, but we manage around it. We help to cover shifts where we can, they don’t like to use agency so at times we can be working with people on our own, but we always support each other if we need to”.

On day one of the inspection, we found the service to be understaffed by two staff members due to the allocation board within the hallway. There had been no attempt to cover the commissioned hours before the start of the morning shift. We asked for this to be addressed. The regional manager covered the shifts with two agency staff members, However, this did not prevent implications for people. One person was delayed in going out in the morning which resulted in the person becoming distressed due to the lack of availability of staff members to ensure the person could go out safely.

We reviewed the staff rotas between the 18 November and 2 December 2024 There were continuous short falls. Whilst the registered manager told us this had been assessed as safe to ensure business continuity, it impacted on staff ability to ensure people remained safe. It also impacted on people’s usual routines and abilities to access the community as they wished. The registered manager reviewed the rota and ensured all shortfalls were addressed. 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. Agency staff were used at the time of the assessment, however, from reviewing their agency profiles 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 and crisis 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.

One relative raised concerns regarding a recent medicine error which resulted in their family member becoming emotionally and physically unwell. Other relatives confirmed they were not sure how medicines were manged in the service but raised no concerns.

Staff who were responsible for medicines administration had completed medicines training, and their competency was regularly assessed. However, staff who have not had medicines training told us they administer prescribed topical medicines daily. This meant untrained staff were administering medicines and were not trained to do so.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences Records we checked showed people were having their regular medicines administered safely. However, records relating to the management of when required and homely remedies medicines needed improvement to be clearer. Medicines audits were completed however they did not always identify some of the issues highlighted during this inspection.