Alexandra Park

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

The service is registered to support a maximum of 32 people. At the time of the inspection, 8 people were supported under the CQC regulated service. 3 people used the ‘care home’ model of care and 5 people were supported under the independent supported living service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

Staff followed effective processes to assess and provide the support people needed to take their medicines safely. However, further improvements were needed in relation to medicines records which weren’t always completed correctly. The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles.

An effective system to ensure safeguarding allegations were appropriately managed and monitored was not fully in place. Staff however, did not raise any safeguarding concerns. They spoke positively about people’s care and support. Relatives also considered their family members were safe at Alexandra Park.

Whilst accidents and incidents were recorded individually; these were not all recorded centrally to ensure management oversight and identify if there were any themes and trends, so action could be taken to help prevent any reoccurrence.

An effective system to ensure the principles of the MCA were followed was not in place. Records did not fully evidence that any decisions/restrictions made in people’s best interests had been assessed in line with the MCA and the appropriate individuals involved.

People were supported to eat and drink enough to meet their needs. Where concerns were identified with people’s weight, referrals were made to the dietitian and their weight was monitored. The monitoring of people’s weights was sometimes inconsistent, and a recognised nutritional risk assessment tool was not used. We have made a recommendation about his.

Right Care:

There were enough staff deployed to meet people’s needs. Work was ongoing to ensure people were supported by a consistent staff team.

Records did not always evidence how people were involved in their care, especially those people who were unable to communicate verbally. Relatives spoke positively about how people’s ‘core team’ of staff supported people and promoted their independence. One relative said, “They are very caring, they go out of their way to support them, even when we’re there, they are not bothered about us, they want to be with their carers. If the carers go, they’ll hang onto them.”

Whilst the ‘campus style’ setting did not align with current best practice; the provider was introducing additional features to promote people’s independence and personalise the service. Individual post boxes were being introduced to ensure people could receive their own post; intercom/fob operated gates were being fitted to allow people independent/supported access to the local community and people’s bungalows were being refurbished to meet their individual needs. There was an on-site resource centre that was used for training, social activities and administration for the site. Plans were in place to refurbish the resource centre and outdoor space.

People were supported to maintain their hobbies and interests; however, relatives and several staff said there was sometimes a lack of staff on duty who could drive people’s mobility cars or the company vehicles. This meant that people were not always able to access the local community in line with their needs and wishes. Following our inspection, the manager wrote to us and explained there were now 5 additional drivers onsite and 3 members of staff who were due to start work and were also drivers. In addition, 2 new company vehicles had been purchased.

Staff gave examples of how being at Alexandra Park, with the support of staff, had led to an improvement in people's independence and wellbeing.

Right Culture:

An effective quality monitoring system was still not fully in place. We identified shortfalls relating to the management of medicines, the assessment of risk including infection control, records relating to people’s involvement and the MCA. Relatives told us that further improvement with communication was required. They explained the frequent changes in management staff and structure had affected communication. They also said communication was not always timely.

There was a cheerful atmosphere at Alexandra Park. Staff spoke positively about the people they supported and working at Alexandra Park. One staff member told us, “I am happy to come to work now, I can't wait to see people. The [previous] manager’s office was out of bounds – but not now.”

Management staff were honest and open with us during the inspection. They themselves exhibited caring values and spoke positively about the changes and improvements which were being made.

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 inadequate (published 19 September 2022.) There were multiple breaches of the regulations relating to staffing levels and staff training, medicines management, infection control, person centred care and the overall management of the service.

This service has been in Special Measures since 19 September 2022. During this inspection the provider demonstrated improvements had been made; however, further improvements were required. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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.

Enforcement and Recommendations

We have identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection. These related to good governance and the need for consent. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents).

Please see the action we have told the provider to take at the end of this report. Full information about CQC's regulatory response in relation to Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents) and CQC’s response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We have made a recommendation in the effective key question in relation to the assessment of nutritional risk. Please see this section for further details

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: Evidence suggested people were not supported have maximum choice and control of their lives because systems to support and deliver care, and staffing numbers and staff training, did not support this. People were not supported to make decisions, engage in activities or access the local community. Care records and information received from staff, relatives and professionals indicated people, or their representatives, were not actively involved in care decisions and insufficient staffing meant people could not make choices easily. People were not always assisted with their medication in a safe and appropriate manner.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care: Care was not person centred, did not promote people’s dignity and failed to support their human rights. People had been left alone without staff support which had placed them at risk and caused them anxiety and distress. People’s dignity was not supported because staff did not always have the correct knowledge and understanding to assist people in the way that would best support their care and wellbeing. Care records were incomplete meaning staff did not always have the correct information to deliver care. Staff training and supervision was not up to date and staff did not always have the right understanding or skills to support people effectively.

Right Culture: The ethos and values of the service were not embedded in care delivery. Management of the service was not robust with incomplete records or documents that were not effectively reviewed and updated. Staff felt unsupported by management. Care staff were unaware some people were supported through an independent supported living process and some people were residents of the service and cared for under the regulated activity, ‘Accommodation for persons who require nursing or personal care.’ People living in supported living arrangements were not always able to exercise choice and live as ordinary life as other citizens. Care plans did not reflect the difference in care and did not support independence and choice. People were not actively involved in decisions about the service they received. The behaviour of leaders did not support people’s involvement in care and help them to express their views and feelings.

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 (published 12 March 2022.) But there were no breaches of regulations. At this inspection we found the provider was now in breach of regulations. The service is now inadequate. This service has been rated requires improvement or inadequate for the last six consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

The inspection was also prompted in part due to concerns received about safeguarding issues, staffing and management of the service. A decision was made for us to inspect and examine those risks.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report. The provider has taken action to address immediate concerns and is working with the local authority and safeguarding teams to address issues.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Alexandra Park on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to staffing and staff training, medicines management, Infection control, person centred care and overall management of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Alexander Park is a campus style service consisting of several bungalows within a discrete complex. The service provides both personal and nursing care and independent supported living assistance to people with a learning disability or mental health condition. At the time of the inspection the service was supporting 21 people; seven of whom received personal care and accommodation and 14 of who were supported on an independent living basis.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

The service consisted of individual bungalows situated in a fenced complex. It was registered for the support of up to 32 people. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by people living in their own individual bungalows. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

At the time of the inspection the service was under organisational safeguard because of recent multiple concerns. The service was working closely with the local safeguarding team and had produced an action plan to address the concerns. Whilst good progress was being made there remained a significant number of actions that still required attention. Relatives felt their relations were safe at the service. People had specific staff teams to help them lives their lives as fully as possible. They were supported to receive medicines in an appropriate manner.

People’s needs had been assessed and support was delivered in line with these identified needs. Staff training and support had improved and staff members had the skills and knowledge to effectively support the people they cared for. People were supported to access appropriate diets and were assisted to attend health appointments to maintain their well-being.

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.

Relatives and professionals told us people were well supported by staff and there was a good understanding of people’s individual preferences and needs. People we visited looked happy and relaxed in staff company. They were supported to make day to day choices about their care and were involved in decision making, as far as was practicable. Staff supported people to be as independent as possible and respected their right to privacy.

Care records had been improved. It was not always clear how identified goals linked with support plans, although plans were detailed and contained good information. People were supported to communicate their needs as much as possible and were assisted to participate in activities or visit the local community. Complaints had been recorded and responded to appropriately.

Staff told us the service had improved over the last 12 months and felt better supported in their roles. A range of quality assurance systems had been introduced to monitor the care people received, although these needed to be fully embedded in the running of the service. People were encouraged to participate in the running of the service wherever possible and were supported to be part of the local community. The provider was meeting legal requirements.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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 (published 13 February 2019).

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. However, we felt that improvements in the service needed to be sustained and the service remains rated requires improvement. This service has been rated requires improvement for the last five consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Alexandra Park is registered for both personal care and accommodation for those requiring nursing or personal care. The service consists of a number of individual bungalows on a campus style site. Some people receive accommodation and personal care as single package under one contractual agreement. Where this happens CQC regulates both the premises and the care provided, and both were looked at during this inspection for these people. The service also provides care and support to people living in ‘supported living’ settings, so that they can live as independently as possible. In supported living people’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support. At the time of the inspection there were 22 people using the service. Seven people were receiving accommodation and personal care under a single package and 15 people were receiving personal care and support through a supported living arrangement.

Although the service was delivered from a campus style site, separated from the local community, the care service and its managers had an awareness of the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service were supported to live as ordinary a life as any citizen.” Registering the Right Support CQC policy.

At the last inspection we had recommended that the provider improved documentation, particularly in relation to risk. At this inspection we found records relating to both risk and care remained complex, difficult to follow and were not always complete. Risks with regard to the equipment and physical environment of the service were monitored and appropriate safety certificates were forwarded to us. The provider had a safeguarding policy in place and any issues had been investigated and dealt with appropriately. The service had in place contingency plans to support people in the event of emergencies.

Medicines were not always managed effectively or safely. Care records did not always indicate how staff should support people with medicines and there was limited information about how people should be supported with creams. Management and administration of medicines was not always carried out in line with NICE guidelines.

Accidents and incidents were appropriately recorded and reviews took place to consider how best to manage any future matters. The service considered how the provision of care could be changed or improved in light of events or recommendations.

People and staff told us sufficient staff were employed to support people’s personal care needs. Care was delivered to individuals by a small number of care staff in individual bungalows. Staff and people told us having a consistent support team was important. Appropriate recruitment systems were followed to ensure properly experienced and qualified staff were employed.

Systems regarding staff training were not robust. Records presented showed training had not always been refreshed or updated in a timely manner. Systems for checking training had been completed were not actively in place. Staff told us, and records showed regular supervision and annual appraisals had not been undertaken and not been monitored.

We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. We found appropriate systems were in place. Best interests decisions were carried out where people did not have capacity to consent. Some best interests decisions were not always specific. We spoke with the manager about this process.

Prior to using the service people’s needs had been assessed and care was delivered in line with these assessed needs. People told us they were supported to make personal choices and staff encouraged them to have a heathy diet. Staff supported people to maintain their health and wellbeing through regular appointments with various health professionals.

People told us they were very happy with the staff and the support they received. Staff were committed to ensuring people they supported received good quality and personal support. People told us they were helped to make day to day decisions about their care.

People’s privacy and dignity were respected. Staff spoke knowledgably about how they promoted and encouraged independence. People were supported by advocates to express their views and ensure their care met their needs.

Care records contained information that supported staff to deliver person centred care which met the individual’s needs. Evidence of care reviews varied, although more detailed six-monthly reviews were undertaken. People told us they were involved in reviews of their care. As far as practical people were supported to access events and activities in the community. There had been no recent formal complaints about the service.

Staff spoke positively about the registered manager and the overall management of the service. They said the manager was approachable and offered good support. They were positive about their work and said they enjoyed assisting people who used the service.

Audits and checks were in place to monitor the quality of the service, although these reviews had not identified the breaches of regulations we found at this inspection. The quality of records was variable, although daily records were much improved and contained good detail and information. The service was meeting legal requirements by submitting notifications to the Commission and displaying its most up to date rating.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the Staffing and Good governance. You can see what action we told the provider to take at the back of the full version of the report. The rating for this service is requires improvement. This is the fourth time the service has been rated as requires improvement. We will meet with the provider to consider the action needed to improve the service.

Alexandra Park is registered to provide accommodation and personal care for up to 32 people with learning difficulties and mental health needs. It is comprised of 28 single occupancy bungalows and a four bedroomed house, located within extensive grounds. Support is provided over a 24 hour period by staff who are based in individual bungalows and managed from the on-site resource centre. The resource centre is also used for training, social activities and administration of the site. There were 21 people using the service at the time of the inspection.

A registered manager was 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.

We last inspected in January 2017 when we carried out an unannounced comprehensive inspection of this service. At that time we rated the service as ‘requires improvement’ and found it was in breach of five regulations. We had found people were not protected from the risk of abuse, the Mental Capacity Act 2005 (MCA) was not being followed, care was not always person-centred, people were not always treated with dignity and respect and the provider’s quality assurance system was ineffective. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. During this inspection we checked that they had followed their plan to confirm that they now met legal requirements.

The inspection was prompted in part by notification of an incident of a safeguarding nature. These incidents had been brought to the attention of the police and local authority. At the time of the inspection the police were carrying out an investigation into the incident. The information shared with CQC about the incident indicated potential concerns about how people were safeguarded from abuse. This inspection examined those concerns.

At this inspection we found the provider was no longer in breach of any regulations. The provider and registered manager had made significant improvements, but some areas for improvement remained. The rating for the service remained 'requires improvement'.

Since our last inspection the provider had strengthened their safeguarding procedures. Staff had undertaken more training focusing on people's rights, and what constitutes institutional abuse. More stringent checks were carried out of records, and support plans were reviewed to ensure they were promoting people's rights. We have recommended safeguarding training is provided to people who use the service, appropriate to their needs.

Risks were monitored and mitigating actions to reduce potential risks had been identified. Records were repetitive and risks assessed across multiple care documents. We recommend the provider reviews their records to ensure key information is consistently recorded.

The areas of good practice which we found at the last inspection had been maintained. Accidents continued to be monitored and where possible action taken to reduce future risks. There were enough staff to meet people’s needs and robust recruitment processes had been followed.

Medicines were administered safely, by staff who had undertaken training and competency assessments.

The provider had reviewed all decisions made on people's behalf to ensure they were in line with the MCA. Restrictions placed on people had also been audited and many had been reduced or removed altogether. 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.

The provider had shown a commitment to investing in training so staff could support people in a way which promoted their rights. Since our last inspection staff had followed a programme of training designed around the needs of people at the service. All staff had received positive behaviour support training. Which focussed on how by understanding fully people's needs, preferences and backgrounds, staff could present themselves and provide support in a way which minimised people feeling anxious or aggressive. The detailed care plans in place to describe to staff how they should respond to people when they displayed behaviour which might be challenging were now being followed, and reviewed more regularly to ensure they stayed up to date.

Restraint was practiced when people were putting themselves or other people at risk of harm. The use of restraint was monitored and any usage was reflected on after the incident. Staff had all had training in how to restrain people safely.

Staff received training, supervision and annual appraisals to ensure they had the skills and knowledge to meet people’s needs. Supervision records showed the frequency of training differed across the staff team, and not all staff received it as often as detailed in the provider's policy. The registered manager told us they would address this.

People were involved in planning their meals and shopping for their food. External healthcare professionals were involved to ensure people’s general health and well-being was maintained.

People told us they liked their staff team, and relatives we spoke with told us staff were warm, friendly and had good relationships with people who used the service. We spent time in people's own homes and in the communal areas and saw people enjoyed positive relationships with staff. They knew each other well, and we saw lots of examples of people and staff laughing and joking. Staff were knowledgeable about people's needs.

Staff supported people to identify and work towards goals, many of these focussed around being more independent. We saw that due to the reduction of restrictions, that people were able to be more independent in their own homes.

Care records remained vast, with areas of duplication, and documents where key information had been omitted. Overall care records were detailed and individualised to the person supported.

The provider had introduced more robust ways of monitoring the service. People's daily records of their care and support were monitored on each day by managers to ensure any issues would be identified and rectified quickly. A number of audits were carried out to ensure risk assessments and support plans were up to date and meeting people's needs. Representatives from the provider's quality team visited the home regularly to carry out in-depth audits of the quality of the service. We could see actions from these quality checks were identified and shared with staff to drive improvements.

Our last inspection identified a reduction in the number of managers. The provider told us this would be reviewed, however management staffing remained the same at this inspection. Some staff fed back they felt managers did not have enough time as their responsibilities within the service had grown. After our inspection the registered manager informed us two new posts within the management team had been created. However the registered manager still had to split their time between registered manager for Alexandra Park and area manager for two other of the provider's services. We were advised this was still under review.

Relatives and staff spoke highly about the management team. They told us the registered manager and support managers were making improvements within the service and were a visible presence.

People who used the service, relatives and staff had been asked for their feedback on how the service was run.

Alexandra Park is registered to provide accommodation for up to 32 people with learning difficulties and mental health needs. It is comprised of 28 single occupancy bungalows and a four bedroomed house, located within extensive grounds. Support is provided over a 24 hour period by staff who are based in individual bungalows and managed from the on-site resource centre. The resource centre is also used for training, social activities and administration of the site.

A registered manager was 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.

The service was last inspected in August 2015 and at that time we rated the service as ‘requires improvement’ but it was found to be meeting all legal requirements.

During this inspection we found people had not been protected from the risk of abuse and improper treatment. We found entries within two people's care records which detailed safeguarding incidents. These records had been signed by a team leader but staff had not identified the improper treatment or informed the registered manager. During our inspection two safeguarding referrals were made to the local authority who are investigating the incidents.

Accidents were monitored and reviewed by the registered manager. Action had been taken to reduce the risk of them reoccurring.

People, relatives and our observations confirmed there were enough staff to meet people’s needs. Records showed safe recruitment processes had been followed.

Staff had been trained to administer medicines and followed good practice. Before our inspection the provider had noted there had been an increase in medicine errors, but action had been taken to address this, staff were in the process of receiving additional training in this topic.

Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’.

The MCA had not always been followed. Some decisions had been made on people’s behalf, however the provider could not demonstrate how the person’s capacity had been assessed or that they had considered the principles of MCA and ‘best interests’ in determining the decisions. Where capacity assessments had been undertaken these were often broad, and not decision-specific. People's care plans described their routines, and stated these plans were in people's best interests, but information had not been provided for staff about how to balance people's right to make choices with their planned routines.

Where people displayed behaviours which may challenge staff, such as anxiety or aggression, detailed care plans were in place to describe to staff how they should respond to people. However these had not always been followed. Staff had introduced new responses which were not based on an assessed need, care planned or evaluated. This meant people could be at risk of receiving inconsistent or inappropriate care.

Where restraint was practiced, additional recording was in place to monitor the use. We found two incidents where people had been restrained but these additional monitoring records had not been completed. On one of these occasions and non-approved method had been used.

Staff received training and supervision to ensure they had the skills and knowledge to meet people’s needs.

People were involved in planning their meals and shopping for their food. External healthcare professionals were involved to ensure people’s general health and well-being was maintained.

Whilst we found records which showed two people who used the service had not always been treated with dignity and respect, relatives we spoke with told us staff were kind and caring. We observed positive interactions between staff and people who used the service. People appeared relaxed and staff were knowledgeable about their needs.

People's independence had not always been promoted when restrictions had been put in place to maintain people's safety. Staff and relatives told us people were encouraged to be independent. Relatives told us they were included in planning people's care and that they were kept up to date with any changes to their relative’s needs.

Care plans were varied. Some were very detailed and gave clear information for staff. Other decisions about people's care had not been communicated well to staff which meant people were at risk of inconsistent care.

Care records were large, it was difficult to know where specific documents were stored, and some documents were poorly completed. However they did contain personal information about people's needs and personal preferences.

The provider, registered manager and staff within Alexandra Park undertook a schedule of audits and quality checks. However this system was not effective and robust in monitoring the quality of the service provided. None of the shortfalls which we identified during this inspection had been highlighted by internal checks.

Since our last inspection the management structure had been reduced. The registered manager had taken on additional responsibilities for the provider organisation, and the support manager positions within Alexandra Park had been reduced from three to two.

Relatives and staff spoke highly about the management team. They told us the registered manager and support managers were making improvements within the service and were a visible presence.

People who used the service, relatives and staff had been asked for their feedback on how the service was run.

We have identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.