Alderson House

Alderson House is a residential care home providing personal care to up to 27 people who may be living with dementia or mental health needs. At the time of the inspection, 13 people were using the service.

People’s experience of using this service and what we found

Risks to people’s safety and wellbeing had not always been assessed, recorded and mitigated and care plans were not always up to date. People’s medicines were administered safely by knowledgeable staff, but protocols for ‘as and when’ required medicines were not always in place and medicine storage temperatures were not always effectively monitored.

Quality assurance systems had not identified or addressed all the shortfalls found during the inspection which included servicing of lifting equipment, medicines protocols, care records, risk assessment and care planning including consent records.

Staff recruitment processes were safe and the provider had reviewed and updated their procedures relating to volunteers, contractors and other visitors to the service to ensure they were safe to be around vulnerable people. There were enough staff on shift to keep people safe and to meet their needs in a timely manner. Staff understood their responsibility to report safeguarding concerns and any concerns had been reported to relevant professionals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; although the policies and systems in the service did not always support this practice.

People gave positive feedback about the variety and quality of the meals. Staff were knowledgeable about people’s specific dietary needs and provided appropriate meals. Where people’s fluid intake needed closer monitoring, records were not always fully completed. Staff were kept updated about changes in people’s needs and referrals to health care professionals were made in a timely manner.

Staff were kind, caring and respectful and had received an induction and training appropriate for their roles. We received positive feedback about end of life care provided by the service and saw a wide range of activities were available to help people maintain their emotional well-being.

Systems were in place to gather feedback from people, their relatives and staff to develop the service. Staff were positive about how they were supported by the provider and the registered manager. The provider and registered manager were open and honest about how the service was operating.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 14 April 2022 and this is the first inspection.

Why we inspected

This inspection was prompted in part by notification of an incident regarding an informal volunteer at the service. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk regarding recruitment processes and ensuring people were suitable to be on site with vulnerable people. This inspection examined those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection that people were at risk of harm from this concern. However, we did find other areas of concern. You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have made recommendations regarding medicine processes and systems for consent and the Mental Capacity Act 2005.

We have identified breaches in relation to assessing risk, quality assurance systems and complete and accurate records at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.