Alexander Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm

This is the first assessment for this service under a new provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The leadership team did not always carry out analysis to look for themes, trends and lessons learnt. This meant that staff were not involved in actions taken to aid in learning from events at Alexander Court Care Home.

However, where accidents and incidents had occurred, staff had a proactive culture and sought appropriate assistance for people, for example people who had sustained injuries from falls were assessed by healthcare professionals or emergency services in a timely manner.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The leadership team told us that they carried out an assessment prior to a person moving into the service. This helped ensure Alexander Court Care Home would be the most suitable place for the person to live and that staff could meet their needs. We reviewed the preadmission documentation of the newest person to move to Alexander Court Care Home and found it to be concise and informative for staff to be able to support the person’s needs on admission to the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff had received safeguarding training and were aware of the types of abuse and how to report them to leadership or directly to local authority.

However, there was not an effective safeguarding monitoring system at the service, and we found not all safeguarding incidents had been reported to the local authority. The safeguarding log had not been fully completed to document outcomes and lessons learnt.

When we informed the leadership team, they were proactive with addressing our concerns and referred safeguarding incidents to the local authority retrospectively and have reviewed and made improvements to the services safeguarding monitoring system.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found people’s diabetes care plans had insufficient information to support staff in supporting people’s diabetes. For example, blood sugars were not being recorded, and staff were not aware a person had their libre glucose monitoring device on them. People with daily fluid intake targets who did not reach the fluid target on consecutive days had no action taken. This put people at risk; however, we found no harm had come to people.

The leadership team promptly implemented blood sugar recording forms to document peoples blood sugar levels and staff received refresher training on libre device use. The manager advised that the district nurse team were currently supporting people with insulin administration.

The manager reviewed all people who had daily fluid targets and people who had not met their daily fluid target on consecutive days were reviewed by the GP.

The provider did not always detect and control potential risks in the care environment. For example, during our inspection, we found people’s toiletries were not always stored safely as risk assessed by the service. This put people at potential risk of consuming substances which could be harmful. The entrance door to the home was broken and not locking, we found the door open several times during our first day of inspection. People requiring support when accessing the community could exit the home and potentially be at risk. We found no one had been put at risk.

We shared our concerns with the leadership team who acted promptly to manage changes and put strategies in place to protect people from the risks we identified.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had rotas in place which showed planned staffing levels and gaps requiring support from agency staff. The leadership team had been recruiting to fill current vacancies.

People told us that they felt supported by the staff. One person told us, ‘The staff always have time for me.’

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The environment was clean and tidy. Cleaning schedules showed daily, monthly and deep cleans were completed throughout the service.

Staff had access to personal protective equipment (PPE) to use when supporting people with their personal care.

The provider did not always make sure that medicines and treatments were safe, for example the service did not complete a running count of people’s medicines on the MAR (Medicines administration record), this meant the provider did not have oversight of medicines stock for people in the service. When we checked the medicine count, we found a discrepancy in a person’s medicine. The leadership team acted promptly in investigating the missed medicine, which did not impact on the person.

The manager had undertaken monthly audits which did not identify the lack of running counts for people’s medicines. This put people at risk, we found no incidents of harm to people.

When we raised our concern with the leadership team they implemented a running count of each person’s medicines.

We found staff competencies were assessed to make sure the support they offered people to take their medicines remained safe and consistent.