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Alexandra Court Care Centre Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 26 July 2019

About the service: Alexandra Court Care Centre is a residential care home that can provide personal and nursing care to a maximum of 72 people. There were 61 people using the service at the time of the inspection, some of whom were living with dementia.

People’s experience of using this service: The provider took over the running of the service in February 2019. Until very recently there had been insufficient staff on duty; the new provider had used a care staffing tool which was not sufficiently accurate when calculating people’s complex health care needs. Staffing levels had been reduced and this had impacted on the delivery of care to some people and affected their health and welfare.

For example, people had not always received their medicines as prescribed, which affected their treatment. Risk had not always been managed to ensure people’s safety. This had impacted on their safe care, health and wellbeing. In one instance a person’s pain and distress had not been well-managed and another person had not been provided with the correct pressure relieving cushion.

People had not always had their needs met in ways they preferred, and in a timely way; this had resulted in one person being admitted to hospital for treatment that could have been provided in the service. The reduction in staffing numbers also impacted on the way the service was managed and the time available for the new registered manager to have oversight of the care of people with nursing needs.

There was a delay in the introduction of the new provider's own quality monitoring system. There was also a crossover regarding documentation, which left a newly registered manager and staff team managing different systems of recording. Records were not consistently accurate and up to date. The initial transition from previous provider to new provider could have been managed much more effectively. The provider’s audit system will need time to be fully carried out.

Complaints had been received about the levels of personal care and health care and treatment delivered to people; these had resulted in safeguarding investigations. Some of these were still being investigated by the local safeguarding team. In discussions, staff knew the different types of abuse and knew to report concerns to management.

There were positive comments about the care staff approach but there were also comments from relatives that this could be improved to be more caring and sensitive. Staff had not consistently gained consent before carrying out tasks such as placing clothes protectors on people. However, people were supported to have maximum choice and control of their lives were possible and staff supported them in the least restrictive way; the policies and systems in the service supported this practice.

People’s nutritional needs were met and menus provided them with choices for the main meals. Those people on textured meals such as pureed, due to swallowing difficulties, had limited choices for desserts.

Staff received training and supervision. There were gaps in training records when staff required courses or updates in training. However, these had been identified by the registered manager. A supervision and appraisal system had just been started following the new provider’s way of working. The provider had a safe system of staff recruitment.

Following the inspection, the registered manager and senior management had reflected on the concerns raised by relatives, the local authority contract monitoring team and the inspection findings. They told us they will produce an action plan and lessons learned document to share with staff and improve practice going forward.

For more details, please see the full report which is on the CQC website at

Rating at last inspection: This was the first inspection of the service since the new provider was registered with the Care Quality Commission (CQC) in February 2019.

Why we inspected: We received information from the local autho

Inspection areas



Updated 26 July 2019

The service was not safe.

Details are in our Safe findings below.


Requires improvement

Updated 26 July 2019

The service was not effective.

Details are in our Effective findings below.


Requires improvement

Updated 26 July 2019

The service was not always caring.

Details are in our Caring findings below.


Requires improvement

Updated 26 July 2019

The service was not responsive.

Details are in our Responsive findings below.



Updated 26 July 2019

The service was not well-led.

Details are in our Well-Led findings below.