Alderlea Care Home

The provider had not always ensured people received safe and well-planned care. Care plans and risk assessments did not always contain enough information to guide staff, including for wound care, moving and handling, and new admissions. Medicines were not always managed safely. Records evidenced that medicines were not being received, stored and recorded properly. Although we found no evidence that people had been harmed, the provider's systems had not identified or addressed these issues.

We found some infection prevention and environmental concerns, including items being stored on the floor, and toiletries being left unsecured in people's bathrooms. While these issues were addressed quickly, they highlighted weaknesses in oversight and monitoring. Fire safety arrangements also required improvement. The provider could not readily provide key fire safety records or evidence of recent fire drills, and staff could not recall taking part in drills. Although no immediate fire risks were identified and action was taken following feedback, the provider could not demonstrate effective oversight of fire safety arrangements.

Audits had not been completed consistently. Care plans and risk assessments lacked sufficient detail to guide staff when providing care. Incident and accident records were not analysed effectively to identify themes, trends or learning. Records relating to the provision of oral care, hydration monitoring, and wound management were not always robust. Staff training compliance required improvement to ensure staff had completed mandatory training and had the knowledge and skills required to provide safe care.

Despite these shortfalls, people and their relatives were positive about the care provided and spoke highly of staff. The service demonstrated a caring culture with committed staff. However, further work was needed to embed effective governance systems and ensure care was delivered safely, consistently and in a person-centred way across all areas of the service.

The management team were receptive to feedback and took prompt action to address concerns identified during the assessment.

The service was in breach of legal regulations in relation to the safety of the service, safe staffing, and good governance and oversight of the service. We have asked the provider for an action plan in response to the concerns identified during our assessment.