Archived: Alexandra House Nursing and Residential Care Home

The service had a registered manager in place. 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.

Prior to this inspection, the ill health one of the business partners meant they had been unable to be involved in the day to day running of the service as they had in the past. This meant that the other business partner and the registered manager had sole responsibility for the day to day running of the service.

Alexandra House Nursing and Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Alexandra House Nursing and Residential Home is registered to provide a service to 25 older people, some of whom may be living with dementia. At the time of inspection there were 19 people using the service.

Following this inspection we were so concerned that we informed Norfolk County Council and the Clinical Commissioning Group (CCG) of our findings. We also took urgent action to prevent the service taking on new admissions.

The service was not safe. Risks in the premises had not been identified and action had not been taken to protect people from harm. Equipment had not been serviced by competent persons to ensure it was safe for use. Appropriate checks had not been carried out on the water systems and fire safety systems to ensure peoples health, safety and welfare.

Risks to people were not being planned for or appropriate actions taken to minimise these. This included risks associated with dehydration, malnutrition and pressure ulcers. People who were at risk of choking were not being supported and supervised appropriately to reduce this risk. Systems were not in place to protect people from the risks of abuse. Staff had not received safeguarding training.

The service was not consistently clean and the registered manager had failed to address concerns about cleanliness which were observed by the CCG in June 2018.

There were not enough staff to consistently meet the needs of people using the service, to include their social and emotional needs. The service did not practice safe recruitment procedures to ensure that staff were of good character and were safe to work with people living within the service.

Medicines were not managed or administered safely. Some people had not received their medicines in line with the instructions of the prescriber and the service had taken no action regarding this.

The service was not complying with the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People’s capacity was not assessed appropriately and the service did not encourage and enable people to make decisions.

Staff did not receive appropriate training in subjects relevant to the people they cared for. This included training in using equipment such as hoists. Staff did not have the opportunity to have supervision or one to one sessions with their manager. The registered manager did not carry out clinical supervision of nurses. There was a poor culture in the service with staff including the registered manager not identifying the poor practice of themselves and others.

People were not involved in the planning of their care and their views were not reflected in their care records. Staff did not always uphold people’s dignity and respect. People were not encouraged and enabled to be independent.

People received generic care which was not personalised to them as an individual. Not all staff knew people as individuals and care records did not provide information to them about the people they were caring for.

There were no end of life care plans in place for people. This meant that the service could not ensure people’s preferences were met at the end of their life. People did not have access to meaningful activity and engagement. People we spoke with told us they were bored.

There was no quality assurance system in place at the service and the registered manager failed to identify the shortfalls we found. This meant that people continued to receive poor quality care which did not meet their needs. The provider had not implemented a system to ensure that an appropriately qualified person was overseeing the quality of the service and performance of the registered manager on their behalf.

The registered manager did not have a knowledge of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 or the framework by which we inspect care homes.

The overall rating for this service is 'Inadequate' and the service therefore is in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than

12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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.

People were supported by staff who understood safeguarding procedures and were able to recognise the signs of potential abuse.

Risks to people had been thoroughly assessed and plans put in place to manage these risks while enabling people to live their lives without unnecessary restriction.

Robust recruitment procedures had been followed to reduce the risks of employing staff unsuitable for their role. There were sufficient numbers of staff deployed to meet people’s needs. Staff received comprehensive training to enable them to meet people’s care and support requirements.

People were given support to take their medicines as prescribed. However, we identified that the medicines auditing procedure was not always effective.

People’s nutritional needs were met and they were supported to access healthcare services if they needed them. People’s health needs were closely monitored and any changes to their needs were immediately reflected in their care plans and the care that they received.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The manager and staff understood the MCA and ensured that consent to care and treatment was sought in line with legislation and guidance.

People were supported by staff who showed respect and cared for them as individuals whilst maintaining their dignity. People were encouraged to make their own decisions where possible and their consent was sought appropriately.

People and those important to them were involved in planning their care and agreeing how it was delivered. People’s independence was promoted and their care was delivered in the way they wished by staff who were knowledgeable about their needs.

People who used the service and staff who supported them were able to express their views on the service. People were supported to make complaints and were confident that these would be heard and acted upon. The service maintained good communication with people who used the service and their families.

We considered our inspection findings to answer the five questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found based on our observations during the inspection. We looked at written records, including people's care records, staff personnel files and medication administration charts. We spoke with two people who used the service. We could not speak with most of the people about their experiences due to their communication needs, so we spoke with two relatives of people who were visiting the service. We also spoke at length with the manager, the owners and four members of care staff.

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

Is the service caring?

One person who used the service told us, "It's very, very nice here and the food is lovely." Two relatives of people who used the service both told us that staff were always attentive to people's needs and there were plenty of staff around to help. We observed the care and attention people received from staff. All interactions we saw were appropriate, respectful and friendly and there was a pleasant and caring atmosphere throughout the home.

Is the service responsive?

We saw that care plans and risk assessments were kept up to date and were regularly reviewed. Staff told us the manager and the owners were approachable and they would have no difficulty speaking to them if they had any concerns about the home.

Is the service safe?

The accommodation was adapted to meet the needs of the people living there, in parts was suited to caring for people with limited mobility and there was a maintenance plan in place. The home was warm and clean and was personalised to the people who lived there. People were protected by effective staff recruitment systems. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines.

Is the service effective?

People we spoke with were satisfied with the care and support they received. No one raised any concerns with us. The owners, the manager and staff we spoke with were knowledgeable about individual people's care needs, and this knowledge was consistent with the care plans in place.

Is the service well led?

Staff said that they felt well supported by the manager, there was a good team ethic and they were able do their jobs safely. The manager undertook regular checks, for example on medication systems and care plans to check they were correct and kept up to date. Whilst feedback received during the inspection process was positive, the provider could not demonstrate formally the satisfaction levels of staff, families, care professionals and people who use the service through quality assurance mechanisms.

We looked at the care records of four people who used the service. These were comprehensive and detailed and included information about the person which showed that the person or their representatives had been involved the care planning..

We found that staff were well supported through training and supervision and regular staff meetings. The service was well managed and the providers played an active role in the day to day running of the service along with the registered manager.

Procedures were in place to ensure that any safeguarding concerns were investigated and reported to the appropriate bodies. Audits and risk assessments ensured that any risks to people who used the service were minimised.

Although processes were in place to ensure that people received high quality, safe and effective support, the provider agreed that they needed a more formal structure to their quality assurance measures and would reintroduce questionnaires to assess this.