Background to this inspection
Updated
7 July 2023
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 Care Act 2014.
Inspection team
The inspection was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Alexandra House is a care home providing personal and nursing care for 25 people, some of whom were living with dementia, at the time of the inspection. The service can support up to 38 people in one adapted building across two floors. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
The service did have a manager registered with the Care Quality Commission.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.
During the inspection
We spoke to 7 people and 3 relatives. We observed the environment of the home and the interaction between people and the staff. We spoke with 6 members of staff including, the provider's representative, the deputy manager, the nurse, 2 care workers and housekeeping staff.
We reviewed a range of records. This included 4 people's care records and medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service including policies and procedures.
Updated
7 July 2023
About the service
Alexandra House is a care home providing personal and nursing care for 25 people, some of whom were living with dementia, at the time of the inspection. The service can support up to 38 people in one adapted building across two floors. At this inspection we found improvements had been made and the home was no longer in breach of regulations.
People's experience of using this service and what we found.
Robust systems were in place to ensure people received their medicines when they required them, this included time specific medicines.
Risk assessments contained detailed information to keep people safe. Falls management was monitored and analysed to note themes, trends and when other professional involvement was required.
We were assured the provider was following infection control guidelines.
Systems were in place to ensure staff were deployed for people to receive effective care and treatment. However, we had mixed comments from people and staff with regards to the level of staff at busy times.
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.
The management team showed leadership and were clear about their roles. They were open and honest and we received positive feedback on the management of the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Requires improvement (25 August 2022) with three breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We last inspected the service in August 2022 and at that time we had concerns regarding storage of medicines, infection control, managing risks to people, staffing levels and governance of the home. Alexandra House was rated required improvement overall.
This inspection was carried out to follow up on action we told the provider to take at the last inspection. 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.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Alexandra House Eastwood on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.