Alderson House

Updated 4 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by 2 inspectors on the first day and 1 inspector on the second day.

Service and service type

Alderson House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Alderson House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We looked at information sent to us since the last inspection, such as notifications about accidents and safeguarding alerts. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We contacted the local authority safeguarding and contract teams for feedback. We used all this information to plan our inspection.

During the inspection

We spoke with 6 members of staff including care staff, senior staff, the chef, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 2 people who used the service, 4 relatives and observed staff interactions.

We looked around the home to review the facilities available for people and the infection prevention and control procedures in place. We also looked at a range of documentation including care files and daily records for 4 people and medication administration records for 2 people. We looked at 3 staff recruitment files and reviewed documentation relating to the management and running of the service such as staff rotas, training and audits.

Updated 4 May 2023

About the service

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.