Alderbrook Care Home

At the time of the assessment there were 30 people living at the service. This was the first inspection of the service which was registered 10 November 2023. The assessment included 3 site visits with other information and evidence reviewed remotely.

At the time of the assessment the home was planning to change its name from Alderbrook Care Home to Silver Lodge. This was still under review when the assessment was completed.

Alderbrook Care Home is located next to Alderbrook Nursing Home; both services are operated by different providers. During our inspection of Alderbrook Care Home, we found the two services were operating as a single location in some areas, for example, sharing staff and elements of management oversight. We are following this up with both providers outside of the assessment process and prompt action is being taken to address this.

Instability in leadership had significantly affected the service. Over a short period of time, 2 interim managers had been in post, and at the time of the assessment the registered manager position was vacant. This ongoing lack of stable and consistent leadership created uncertainty for staff and contributed to confusion about roles and expectations.

Staff described feeling unsupported and reported a culture that focused on blame rather than promoting learning, professional development, or continuous improvement. This was acknowledged by the management team, who confirmed that action was being taken to improve the culture within the home.

Governance arrangements were not sufficiently robust to ensure safe, effective, or sustainable care. Clear lines of accountability were lacking, and governance processes did not reliably identify risks, monitor performance, or drive improvements. Although some audits had been carried out, limited action had been undertaken, due to instability of the management team.

We found supervisions and team meetings were not always completed. Accidents and incidents were not appropriately reviewed to ensure learning could be shared. Care plans and risk assessments were not always up to date and accurate.

We found that medicines were mostly managed appropriately. Staff also monitored people’s health for specific conditions. For example, blood glucose monitoring records prior to insulin administration and blood tests for a person who was prescribed a blood thinning medicine.

The service was clean and the environment was personalised. Feedback was welcomed about improvements needed and leaders were committed to developing the service to ensure safe care.

Following feedback from inspectors, the interim manager and wider management team recognised the need for improvement and began to address the concerns identified.

We identified breaches of regulation in relation to safe care and treatment and governance. We have asked the provider for an action plan in response to the concerns we found during this assessment.