Alexandra Court Care Centre

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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment and we requested an improvement action plan from the provider.

This service scored 56 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. We saw some evidence of analysis of accidents and incidents but this was not competed consistently. Analysis of accidents and incidents to identify lessons learned did not highlight themes, trends and outcomes which could be shared with staff teams for learning and continuous service improvement. The provider had not ensured the review of accidents and incidents were embedded into practice.

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’s electronic care planning system was used to create information packs which contained updates and information about the care and support people received. These information packs were used to share key information when people moved between services, for example, when they went to hospital for treatment.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how this could be achieved. 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. The principles of the Mental Capacity Act 2005 (MCA) were understood by the provider and there were processes in place to review people’s capacity in line with the MCA. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found there were some gaps between people's DoLS expiring and new applications being submitted by the provider. We made the provider aware of these gaps and asked them to take action.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care was not always delivered in line with their care plans. Records did not support people received repositioning and turns, to relieve them from pressure, as frequently as detailed in their care plan. For people who required hoisting, there were no sling loop configurations in their care plan. There was, however, no evidence people had been harmed as a result of these areas highlighted for improvement.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Checks on the care environment were completed and records were maintained accurately. Hoists and equipment were serviced line with statutory guidelines and legislation.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care which met people’s individual needs. Members of staff were recruited, on the whole, safely although we identify some shortfalls in record keeping. We provided feedback to the management team who took action. Whilst there were sufficient members of staff on shift, deployment of staff could be have been managed more effectively. Members of staff were often task focussed and did not engage with people proactively. When we spoke to people and their families, they told us they felt there were insufficient numbers of staff at all times. One family member said, “After a fall at the care home, [relative] was sent to [hospital] with [a member of staff] who did not speak to [relative] at all.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We identified some areas for improvement in relation to infection prevention and control. Some areas of the care home had strong odours and feedback highlighted cleaning practices and schedules were not always effective. Personal protective equipment (PPE) was available for members of staff to use but it was not always disposed of effectively. We provided feedback to the management team who took appropriate action.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. When we reviewed stocks of medications, we found the tallies matched the amount of medication in stock which indicated people received their medications as prescribed. There were appropriate records in place for patch applications which required daily checking to ensure they were still in place. However, we did identify some gaps in checking people’s patches. We also saw evidence thickener for drinks was not always stored securely. We provided feedback to the management team who made changes to mitigate any on-going risk. These changes and improvements needed to be embedded and sustained to ensure continuous improvement.