Keychange Charity Alexander House Care Home

Keychange Charity Alexander House Care Home is a care home that provides care and support for up to 20 people. At the time of our inspection there were 15 older people using the service including those with dementia. The care home accommodates people in one building.

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

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; the policies and systems in the service supported this practice.

People, their relatives and staff said that Keychange Charity Alexander House Care Home was a safe place to live and for staff to work in. Any risks to people were regularly assessed and reviewed. This meant people could take acceptable risks, enjoy their lives and live safely. Accidents, incidents and safeguarding concerns were reported, investigated and recorded. There were sufficient appropriately recruited staff to meet people’s needs. Trained staff safely administered medicines and prompted people to take them. When required staff used Personal Protection Equipment (PPE) effectively, safely and the infection prevention and control policy was up to date.

People and their relatives told us effective care was provided. People were not subject to discrimination and their equality and diversity needs were met. Staff were well trained and supervised. People and their relatives thought the care staff provided was good and met people’s needs. People were encouraged by staff, to discuss their health needs, any changes to them, and concerns were passed on to the management and appropriate health care professionals. This included any required transitioning of services if people’s needs changed. Staff protected people from nutrition and hydration risks and they were encouraged to choose healthy and balanced diets that also met their likes, dislikes and preferences.

People were provided with care and support in a friendly manner and staff paid attention to small details that made all the difference. People felt respected and staff acknowledged their privacy, dignity, and confidentiality. They were encouraged and supported to be independent and do things for themselves, where possible. This improved their quality of life by promoting their self-worth. Staff cared about people, were compassionate and passionate about the people they provided a service for.

The provider was responsive to people and their needs were assessed, reviewed and care plans were in place that included any communication needs. Staff provided people with person-centred care and they had choices, and were encouraged to follow their routines, interests and maintain contact with relatives and friends. They were also supported to interact with others living at the home so that social isolation was minimal. People and their relatives were given appropriate, easy to understand information about the home to make their own decisions regarding whether they wished to move in. Complaints were recorded and investigated.

The home’s interim management and leadership were visible and there was a culture of openness, positivity and honesty. Currently there was not a registered manager in place, although interviews were taking place during the inspection. The provider’s vision and values were clearly set out, understood by staff and they followed them. Areas of staff and management responsibility and accountability were identified, at all levels and a good service maintained and regularly reviewed. Thorough audits took place and records were kept up to date. Wherever possible community links and working partnerships were established and kept up to further minimise social isolation. Healthcare professionals told us that the service was well managed and met people’s needs in a professional, open and friendly way.

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

Why we inspected

The last rating for this service was Good (published 20 June 2018).

We undertook this inspection to check whether the service was continuing to provide a good, rated service to people.

The overall rating for the service has remained Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Keychange Charity Alexander House Care Home on our website at www.cqc.org.uk.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

At the last inspection in March 2017, the service was rated Requires Improvement. We found two breaches of Regulations relating to medicines management and quality assurance. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements.

At this inspection we found the provider had made the necessary improvements to meet the Regulations and had improved to an overall rating of Good.

Why the service is rated Good.

People felt safe living at Keychange Alexander House and spoke positively about the care provided to them. Staff knew people well and treated them with kindness, dignity and respect. Relatives and other visitors were welcomed and people were supported to maintain relationships with those who matter to them. People and their relatives spoke about the friendly staff and the relaxed and homely atmosphere. This was evident on both days we visited.

There were enough staff to meet people’s needs. Some relatives told us they would welcome more permanent staff on duty with the home using less agency staff. Recruitment was on-going at the time of our inspection.

Individual care and support needs were fully assessed, documented and reviewed at regular intervals. A new electronic system for care planning provided an effective tool for staff to do this.

Staff had received training around safeguarding vulnerable people and knew what action to take if they had or received a concern. They were confident that any concerns raised would be taken seriously by senior staff and acted upon.

The service understood and complied with the requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). Staff understood the importance of gaining people’s consent before assisting them. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

There was a system in place for dealing effectively with people’s concerns and complaints.

An experienced acting manager had been in post since November 2017 and acknowledged the service was undergoing a period of change. This included some changes of staff, procedures and job roles. Care staff spoken with were positive about the improvements made.

There were now effective systems in place to help ensure the safety and quality of the service provided.

We returned in March 2016 and found that although there had been some improvements, the service continued to breach legislation which related to good governance and staff support. We issued two warning notices) that required the provider to make the relevant improvements within a set time period and maintained the condition the service could not admit any new people into the home.

In August 2016, we carried out a focused inspection and found the service had improved sufficiently to meet the remaining two breaches of legislation and we therefore removed the condition which had previously restricted new residents. The services’ rating remained at ‘requires improvement’ as we needed to see consistent progress over time.

This inspection took place on the 10 March 2017 and was unannounced. Alexander House is a care home that provides personal care for up to 20 older people, some of whom maybe living with dementia. At the time of the inspection, there were 16 people living at the home and one person was temporarily receiving respite care at the home.

The service did not have a registered manager in post, although it is legally required to do so. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The regional manager told us the registered manager had recently resigned and the provider was seeking to recruit a new manager as soon as possible. At the time of the inspection the deputy manager was acting up as the manager.

At this inspection we found areas of concern, namely in respect of the storage and the recording of medicines. With regard to the storage, the provider had identified the issue and was awaiting a new metal cabinet but in the meantime, medicines were not stored as securely as they should have been. The recording of medicines was generally satisfactory; however, we noted a number of omissions over a one week period for a person using the service.

The second issue of concern was regarding the general recording of information about people who used the service. We found some areas where records were not complete and contemporaneous, such as an injury to someone who used the service which had not been appropriately recorded. In addition, the lack of a complaints log meant the provider could not easily identify what action had been taken or if there were any patterns or trends.

We identified two breaches of the Health and Social Care (Regulated Activities) Regulations 2014 during our inspection. You can see what action we told the provider to take at the back of the full version of this report.

People told us they felt safe. The provider had completed pre-employment checks, including criminal records checks, to make sure only suitable staff were employed. Staff were knowledgeable about what they needed to do if they considered anyone was at risk of harm.

People received care from staff that were well trained and supported to undertake their roles and responsibilities. There were sufficient staff on duty to meet people’s needs.

Staff were kind and compassionate. They knew people well and could deliver care in line with the person’s wishes. People could participate in a range of activities dependent upon their wishes and were encouraged to maintain contact with friends and relatives.

The provider supported people’s with their health needs. This included their nutritional needs and ensuring they had access to healthcare professionals as and when they needed them. The service was able to provide end of life care to people should it become necessary.

The provider used a variety of methods to seek the views of people who used the service, their representatives or relatives about the quality of service provision to identify if there were any areas that needed to improve. People told us they felt able to raise issues or concerns with the acting manager and felt their views would be taken seriously.

We saw that risk assessments were completed and reviewed regularly. These helped to ensure people maintained their independence as far as possible. Any accidents and incidents were recorded and reviewed by the acting and regional managers to see if any patterns could be identified.

We carried out this focused inspection to check whether the provider had complied with the warning notices and rectified the legal requirements they were previously breaching. This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Keychange Charity Alexander House Care Home on our website at www.cqc.org.uk.

This service provides accommodation and personal care for up to 20 people, some of whom may be living with dementia. At the time of our visit there were 15 people using the service. There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found the provider had taken the necessary action to improve medicines management and risks to people from unsafe medicines practices were reduced. People were happy with how they received their medicines. Medicines were stored, administered and recorded safely. There was a variety of safeguards in place to check that medicines were administered and signed for as required. Each person who took medicines had a medicines care plan in place and, where relevant, personalised protocols for taking ‘as required’ (PRN) medicines so staff could support them safely with these. There was a homely remedies policy in place.

The provider had made improvements to the support that staff received to do their jobs. Staff received regular individual and group supervision, including extra sessions when required to address any concerns that were raised. Staff had annual appraisals to assess and discuss their development. There was a training programme in place, covering the knowledge and skills staff needed to work with people currently using the service.

People and staff gave us positive feedback about the registered manager and improvements they had made since our last inspection. There was a range of systems in place to assess, monitor and continually improve the quality of the service. The provider used audits and checks to quickly identify and effectively address shortfalls in the quality of the service. Audits of medicines and other care records allowed the provider to make significant improvements in the quality of record keeping.

The above shows that the provider had made the necessary improvements to meet legal requirements they were previously breaching. As a result we have made a decision to remove the condition we had placed on the provider about not admitting any new people to the home. We have however not changed the rating of the key questions and of the location from ‘Requires improvement’ to ‘Good’, because to do so would require consistent and sustainable improvements at the service over time.

Keychange Charity Alexander House provides accommodation for older people who require support with their personal care, some of whom also have dementia. The service can accommodate up to 20 people. At the time of our inspection 17 people were using the service. The majority of people using the service funded their own care.

At our previous inspection the service did not have a manager in post. A new manager was appointed in September 2015 and was in the process of becoming the service’s registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Systems and processes in place to review, monitor and improve the quality of service provision were not sufficiently robust. Audits and reviews had been undertaken which had identified improvements were required to improve the quality of care provision. However, sufficient action had not been taken to address the concerns identified, particularly in regards to medicines management and care records.

Accurate care records were not maintained. Care records were missing some key documents, provided conflicting information about people’s support needs and were not updated in response to incidents that occurred and changes in people’s support needs.

The provider’s system for reviewing training provision had identified that many staff had either not completed the required training that the provider considered mandatory for their role or had not completed refresher training. This meant there were risks that staff’s skills and knowledge were not up to date and in-line with good practice. The provider’s systems to formally support staff were not consistently implemented. There were inconsistencies in supervision arrangements and staff had not received an appraisal.

Safe medicines management processes had not been maintained. There were some discrepancies in stock balances, there were no protocols in place to instruct staff when to administer “when required” medicines, and the homely remedies protocol had not been updated to include everyone at the service.

We saw that improvements had been made to ensure a safe and secure environment was provided. All windows had the appropriate restrictions in place, and fire exit doors had been linked to the fire safety system. Equipment had been maintained and serviced to ensure it was in safe working order. Processes were in place to review health and safety in relation to the environment and equipment used.

Staff were aware of their responsibilities to safeguard people from harm. All concerns were reported to the manager, who liaised with the local authority safeguarding team to ensure appropriate management and protection plans were in place to minimise the risk of harm to people.

People were involved in decisions about their care and consented to the support provided. Staff adhered to the principles of the Mental Capacity Act 2005. This included reviewing the restrictions in place at the service and applying for authorisation to deprive a person of their liberty where appropriate.

New systems were in place to review and monitor incidents that occurred at the service. The manager reviewed all incidents to ensure appropriate action was taken to support the person, and to identify any trends.

Risk assessments had been improved to ensure they were tailored to individuals and identified the specific needs people had. We saw that these were reviewed regularly and informed staff about the support people required to maintain their safety and welfare. We observed staff supporting people in line with their risk management plans.

Staff were aware of people’s care and support needs, and provided them with the level of support they required. This included supporting them with any nutritional needs and liaising with healthcare professionals as necessary.

Staff had built caring and positive relationships with people and their relatives. Staff were aware of people’s communication needs and we observed staff engaging people in conversations. A varied activities programme was available that was tailored to people’s interests and hobbies. Volunteers were used to further enhance the range of activities on offer.

Staff were respectful of people’s right to privacy and supported people to maintain their dignity. Staff were knowledgeable of people’s preferences and individual needs, including in relation to their faith. Staff invited and supported people to practice their faith and made arrangements for religious leaders to visit them.

The service had met the previous breaches of legal requirements in regards to premises and equipment, and safeguarding people from abuse. However, they remained in breach of regulations relating to the safe care and treatment of people, good governance and staffing. Following our last inspection we imposed a condition on the registration of the provider which prevented them to lawfully admit and provide personal care to new people. This became active on 5 January 2016. This condition will continue as the provider continues to be in breach of the regulation in relation to the safe care and treatment of people.

We have issued warning notices against the provider in relation to breaches of regulations in relation to good governance and staffing and these should be complied with by 24 April 2016.

Following that inspection we asked the provider to take action to achieve compliance with the appropriate regulation. The provider sent us an action plan on 4 July 2014 setting out the steps they had taken to do this. During this visit we checked these actions had been completed.

This visit was carried out by a single inspector who helped answer two of our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, from looking at records and from speaking with the team leader on duty. We also spoke with two carers and a member of the domestic staff team. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found at this visit the provider had taken appropriate steps to protect people from the risks of unsafe or inappropriate care. Staff had received appropriate training to protect people from unsafe moving and handling practices. Staff had also received training in supporting people whose behaviours may be challenging and could put them at risk.

Risk assessments had been reviewed and there was appropriate guidance and support plans in place for staff. This helped to ensure people were protected from risks to their health, safety and welfare.

Is the service effective?

People's health and care needs had been reassessed and documented and we saw where people's needs had changed, senior staff took appropriate action to ensure the home could effectively meet the needs of people using the service.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with eight people using the service, four of their relatives, the manager and deputy manager, thirteen staff including 9 care workers and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

There was a Deprivation of Liberty Safeguard in place for one person using the service at the time of the inspection. We saw that this had been made in the best interests of the person, and at the right level, by the local authority. Relevant staff had been trained to understand when an application should be made, and how to submit one. This meant that systems were in place to safeguard people.

Systems were not always in place to make sure that staff learned from events, such as incidents of behaviours which challenged the service. People's needs, for example relating to moving and handling, were not always managed effectively. This meant that people using the service and staff were not protected from unsafe moving and handling systems.

We found the home to be clean, however, most staff we spoke with told us that there had been difficulties in keeping the home clean on weekends since around August 2013. There had also been difficulties recruiting to the weekend domestic role. However, we saw that the manager had recently taken action to improve the situation, such as employing agency cleaners.

Is the service effective?

People told us that they liked the food, and we saw that they received nutrition and hydration to meet their needs. People's health and care needs were not always assessed properly and documented accurately in care plans and risk assessments. There were therefore risks that people might not get the care they needed because comprehensive care plans were not available to support staff consistently to meet people's needs, particularly if they were bank or new staff working at the home.

Is the service caring?

Regular staff knew the needs of people who used the service well. People who used the service made positive comments about the staff, as did the family members we spoke to. People who used the service told us that they liked living here. One relative told us, 'It's marvellous here, they look after [my relative] well.' We saw staff responding to people in a respectful way and respecting people's privacy.

Is the service responsive?

The manager had responded well to a fire enforcement notice, and within four months of receiving it had met all the requirements. The operations manager visited the home regularly to assess quality within the care home. The manager told us how improvements were made and where weaknesses were highlighted from these reports.

Is the service well-led?

We found that the manager had appropriate arrangements in place to respond to complaints and where people had complained, the provider had taken action to resolve complaints appropriately. The service had systems in place to seek the views of staff about the care of people using the service. However, five staff we spoke with did not feel that the providers did not have sufficient regard to their views and experiences.

We also spoke with five visitors who spoke positively about the care provided at Alexander House. One visitor said, 'I think it's absolutely wonderful.' Another visitor told us, 'The manager and the staff are very helpful. I always feel welcome and I am involved in whatever is going on.'

We found that people using the service, or people acting on their behalf, were involved in the planning of care and treatment. Care and treatment was planned and delivered in line with their individual care plans.

We found that there were appropriate arrangements in place for the management of medicines and a satisfactory procedure for dealing with complaints. We noted improvements in training and supervision of staff.

They made positive comments about their life at Alexander House. People said to us, 'I'm perfectly happy, I like it here.' and, 'It's really nice here. I don't have to do anything, they do it all for me.' A regular visitor said, 'The home is marvellous, it really is.'

We observed staff talking to people in a friendly and inclusive manner. We saw that staff respected people's privacy and dignity.

However, although most people said they were happy with the care and support at Alexander House we found that the provider did not have adequate systems in place to ensure that staff were appropriately trained.