Background to this inspection
Updated
22 April 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008
This was a targeted inspection to check whether the provider had met the requirements of the specific concern we had about staffing levels and infection control. We will assess all of the key question at the next comprehensive inspection of the service.
Inspection team
This inspection was undertaken by one inspector.
Service and service type
Alexandra House is a ‘care home’. 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.
The service had a manager registered with the Care Quality Commission. 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.
Notice of inspection
This inspection took place on 16 March 2021 and was unannounced.
What we did before inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We met with three staff members and spoke with the registered manager by telephone during the site visit. We observed care and support provided in communal areas.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We reviewed contingency planning and policies around infection prevention and control.
Updated
22 April 2021
About the service: Alexandra House is a purpose built two storey care home that provides residential care for up to 17 older people, including people living with dementia.
People’s experience of using this service:
People told us they felt safe. On inspection we found that people had not consistently received safe care. Safe food storage procedures were in place, but these were not always followed by staff. Personal emergency evacuation plans (PEEP's) had not been completed for all people and the quick reference emergency evacuation plan required some improvement to ensure people could be evacuated quickly in the unlikely event of an emergency. People’s medicines were administered by trained staff.
The adaptation of the service and the building could be developed further to better support people living with dementia. For example, dementia friendly signage was not used to support people with orientation. We have made a recommendation about creating a dementia friendly environment.
Person centred care and activity needed further development. People’s culture, religion and lifestyle choices needed to be considered in more detail. We have made a recommendation about engaging people in person centred activity.
Risk assessments were in place and reviewed regularly to protect and promote people’s safety. Staffing numbers were sufficient to keep people safe and recruitment procedures ensured that staff employed were suitable for the role.
Staff had a good understanding of the Mental Capacity Act (MCA). Records required further development to provide clear information on what decisions people could or couldn’t make for themselves to ensure they were being supported in the least restrictive way possible.
People received care from staff that were kind and caring. Privacy and dignity was protected and promoted. People had developed positive relationships with staff who knew them well.
The registered manager and provider were open friendly and approachable. They were well respected by the staff team who told us they were supportive. Quality monitoring processes had not always identified inconsistency in recording information. However, the registered manager was taking positive steps to improve the service and maintained oversight with their hands-on approach. They had recently joined networking groups and forums to share and gain knowledge to improve the service.
Rating at last inspection: Not yet rated
Why we inspected: This was a planned first comprehensive inspection.
Follow up: We will continue to monitor the service through the information we receive until we return to visit as per our re-inspection programme. If any information of concern is received, we may inspect sooner.