Alexandra Court Residential Home

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. At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This service scored 78 (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 had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Records demonstrated that the service had effective systems in place to review and analyse incidents and accidents. These reviews resulted in the development of action plans, which were monitored by the registered manager and deputy managers to ensure identified improvements were implemented and sustained.

Learning from incidents was consistently shared with staff through handovers, team meetings and individual supervision sessions. This supported the development of safe, consistent practice and ensured staff remained informed of any changes required to improve care delivery.

Staff received appropriate training to equip them with the knowledge and skills needed to respond effectively to people's individual needs, including specialised training in supporting people living with dementia.

This evidenced a positive culture of continuous learning and improvement, where lessons learned were embedded into everyday practice. As a result, the service was able to reduce the likelihood of incidents recurring and improve outcomes for people using the service.

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 provider had effective systems in place to support safe, coordinated care. They worked collaboratively with a range of healthcare professionals, including GPs, district nurses and hospital teams, to ensure people received consistent, person-centred care and positive outcomes.

Records demonstrated clear engagement with external professionals and effective information sharing to support continuity of care. Staff were able to recognise changes in people's health and wellbeing and responded appropriately by escalating concerns without delay. They worked closely with relatives and relevant professionals to ensure appropriate interventions were implemented promptly.

This collaborative approach helped to ensure risks to people's health and wellbeing were identified and managed effectively. It also promoted timely decision-making, reduced the likelihood of avoidable deterioration, and supported people to receive safe, responsive care that met their individual needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at the service and spoke positively about the care and support they received. One person said, “I am safe, I am not on my own. I am quite happy and will stay here forever.” Another person said,” I have been here about eighteen months. Oh yes, I feel safe, I just do. It’s very nice and homely.”

Staff demonstrated a good understanding of their safeguarding responsibilities and were able to explain how they would recognise, respond to and report concerns about abuse or neglect. Safeguarding training was in place, and records confirmed staff had completed the training required to support them in carrying out their roles effectively.

We reviewed safeguarding records and found that most concerns had been reported appropriately to the relevant authorities when required. However, two incidents involving falls had not been notified to the Care Quality Commission (CQC) in line with regulatory requirements. The registered manager acknowledged this and took immediate action during the inspection to submit the required notifications and review internal processes.

The registered manager worked openly and constructively with healthcare professionals, local authority safeguarding teams and other relevant agencies to ensure concerns were investigated and managed appropriately. This demonstrated a transparent approach to safeguarding and a commitment to learning and improving practice where shortfalls were identified. Records evidenced a transparent and reflective approach to safeguarding, with lessons learned from incidents and concerns used to drive improvements in practice.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people's health, safety, and wellbeing had been comprehensively assessed and were subject to regular review. Risk assessments were detailed, person-centred, and provided clear guidance for staff on how to support people safely whilst maintaining their independence. People were actively involved in the assessment and planning of their care, and where appropriate, relatives and advocates contributed to decision-making processes.

Staff demonstrated a good understanding of individual risks and consistently supported people in line with their assessed needs. For example, we observed staff carrying out regular welfare checks for a person who was walking up and down the corridor, ensuring their safety while respecting their choice and promoting independence.

The service adopted a positive approach to risk-taking. Individualised risk assessments enabled people to make choices about how they lived their lives, balancing safety with their rights, preferences, and independence.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had effective systems in place to monitor and maintain the premises and equipment. These arrangements supported people's safety, wellbeing and quality of life and helped ensure the service remained a comfortable and well-maintained environment in which to live.

People also had access to a well-maintained garden, which provided an attractive outdoor space for recreation and relaxation.

The registered manager provided evidence that the premises, equipment and safety systems were regularly serviced, tested and maintained. Records demonstrated that routine checks were completed consistently, helping to ensure the environment remained safe, secure and fit for purpose. Systems were in place to monitor infrequently used water outlets and to undertake regular legionella checks. Staff had received fire safety training and demonstrated a clear understanding of the actions required in the event of a fire, helping to promote people's safety within the service.

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.

Staff recruitment files were reviewed remotely. These contained the required recruitment documentation and provided evidence that appropriate recruitment checks had been completed. Evidence was available to confirm identity verification, employment references with no unexplained gaps in employment history, right-to-work documentation, Disclosure and Barring Service (DBS) checks, and relevant recruitment and appointment records, including interview notes.

The information contained within both files demonstrated that robust recruitment processes had been followed and that all necessary pre-employment checks were in place to support safer recruitment practices and help ensure the suitability of staff working within the service.

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.

People were supported in an environment where infection prevention and control risks were effectively managed. During the assessment, the home was clean, tidy, and well maintained. Staff demonstrated a good understanding of infection prevention and control procedures and explained how personal protective equipment (PPE) was used to minimise the risk of infection transmission. They were also able to describe the arrangements for cleaning equipment and maintaining hygiene throughout the home. The management team regularly monitored infection prevention and control practices through environmental checks and audits, helping to ensure safe standards were consistently maintained across the service.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored safely and securely, and stock levels checked on the day of inspection were accurate. Regular stock checks of all controlled drugs held were not carried out in accordance with the frequency specified in the home's policy. However, management had identified and acknowledged this issue.

We reviewed the administration of medicines for a resident who received their medicines via a PEG (percutaneous endoscopic gastrostomy) tube. Appropriate procedures were followed and person-centred care was provided to ensure medicines were administered safely and effectively.

Where people were prescribed medicines to be taken 'as required' (PRN), clear protocols were available within care records to guide staff on when and how these medicines should be administered. For people prescribed transdermal patches, rotation charts were maintained and reviewed daily to ensure patches remained in place and to minimise the risk of application site errors.

Regular medicines audits were undertaken, staff training and competency assessments were up to date, and there was evidence that appropriate action was taken in response to medicines errors or incidents. Overall, medicines were managed safely, and systems were in place to support safe administration and oversight.