CQC report explained · a nursing home
What the CQC found at Alexandra Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People experienced delays because there were not enough staff at key times. Risks, incident records and some care records were not consistently managed, although medicines, recruitment and infection control were generally handled safely.
- Effective?
- Requires improvement
- This key question was not inspected during this focused inspection. Its previous rating was carried forward.
- Caring?
- Requires improvement
- This key question was not inspected during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The quality assurance system did not identify the effect of staffing shortages. Some actions were marked complete even though inspectors found that issues remained, and required notifications had not always been submitted.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found delays in care, too few staff at key times and risks that were not always managed.
This was an unannounced focused inspection after concerns about staffing and risks to people's health and wellbeing. Inspectors visited on 24 May and 13 June 2022. They spoke with people, relatives, staff and professionals, and checked care, medicines, recruitment and management records.
Inspectors found that people sometimes waited for personal care, meals and responses to call bells. Staffing was not enough at key times on one unit. Records about accidents, incidents, food, fluids and personal care were not always complete or consistent, so inspectors could not be sure that all concerns had been properly investigated.
Medicines, staff recruitment and infection control were generally managed safely. Relatives said communication had recently improved and that the manager was approachable. However, the quality checks did not identify the effect of staffing problems and some actions were recorded as complete when problems remained.
The overall rating remained Requires Improvement, as did Safe and Well-led. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
Safe recruitment
The provider carried out pre-employment checks, including references and DBS checks.
“Staff were recruited safely. The provider completed a range of pre-employment checks such as obtaining references and Disclosure and Barring Service (DBS) checks.” from the report
Medicines
Medicines were stored securely, records were complete and staff were trained and assessed as competent.
“People received their medicines as prescribed, with all medicines stored appropriately and securely. Records seen were fully completed, with routine audits and stocks checks completed.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including PPE, testing and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Communication
Relatives described better communication and regular information about their family member's care.
“Relatives felt there had been a recent improvement in being engaged with the service. They confirmed receipt of regular communication from staff and newsletters.” from the report
Too few staff
seriousPeople waited for care, meals and call bell responses. Inspectors observed that staff were stretched and could not always meet people's needs promptly.
“There were insufficient numbers of staff deployed to meet the needs of people living at the service.” from the report
Risks and records
seriousRisk controls were not always followed, and records about care, accidents and incidents were incomplete or inconsistent. Inspectors said this placed people at risk of harm.
“Risks to people's health, safety and well-being were not consistently managed. This placed people at risk of harm.” from the report
Weak quality checks
needs fixingThe home's audits and development plan did not reliably identify or resolve problems. Some actions were marked complete even though inspectors found they were not.
“The provider remains in breach of regulation 17.” from the report
Notifications not submitted
seriousThe service had not sent all required notifications to the CQC about concerns. Inspectors identified six incidents where notifications had not been submitted.
“The failure to submit the required notifications was a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009.” from the report
- 01How many staff are deployed on each unit at busy times, including weekends, and how do you cover sickness or shortages?
- 02How quickly are call bells answered, and what action have you taken about waits of more than five and 20 minutes?
- 03How do you check that people receive personal care, meals, food and drinks without delay?
- 04How are accidents, incidents, bruising and safeguarding concerns investigated, recorded and reported to the CQC or other authorities?
- 05Which actions from the home development plan are still outstanding, and how will you prove that they have been completed?
This was a focused inspection of Safe and Well-led, with infection control also checked; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 4 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2022
Alexandra Care Home was rated Requires Improvement; inspectors found caring staff and safe medicines, but staffing, records and management checks were not reliable enough.
This was an unannounced first inspection of the newly registered home. Inspectors visited on 9 November 2021 and reviewed information, spoke with people, relatives and staff, and checked care, medicine and management records.
All five areas were rated Requires Improvement. Inspectors found that people generally felt safe and that staff were kind, but staffing pressures reduced time for personalised care, companionship, privacy and activities.
Care records, risk assessments and mental capacity records were inconsistent between the three units. The home had checks and an improvement plan, but these had not found or fixed important problems. CQC found a breach of Regulation 17 on good governance and asked the provider for an action plan.
Safe medicines
Medicine records were complete, and the home carried out stock checks and audits. Staff also had guidance for medicines prescribed to be taken when needed.
“Medicine Administration Records (MAR) seen were fully completed. Regular stock checks and audits were completed.” from the report
Infection control
Inspectors were assured about infection prevention, testing, protective equipment, visiting arrangements and the home's ability to manage outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staff training
Staff completed an induction and received training, supervision and competency checks. Training was monitored and refresher courses were planned.
“Staff training was monitored via a training matrix and competency checks.” from the report
Health referrals
The home worked with health professionals and made referrals when people needed specialist support, including support with eating, swallowing, wounds and movement.
“We saw evidence of people having been referred to a range of services such as dietitians, speech and language therapists, tissue viability nurses and physiotherapists.” from the report
Staffing pressure
seriousSome people, relatives and staff said there were not always enough staff. Inspectors saw staff were often hard to find and rushed, which reduced time for personal care, companionship and support.
“We saw that staffing levels were consistent with the outcome of the tool but observed that staff were not visible in many areas of the service and were often hurried, moving from task to task.” from the report
Incomplete risk records
seriousRisk assessments were not consistently followed and sometimes conflicted with care plans. This included missing checks for pressure-relieving equipment and conflicting instructions about a person's diet and meal support.
“Risk assessments were not always consistent with the information recorded in people's care plans.” from the report
Privacy and dignity
needs fixingInspectors found that people could be visible from corridors when not fully dressed, and some continence and catheter equipment was visible.
“People were visible from the corridor, without being fully dressed.” from the report
Limited activities
needs fixingPeople and relatives consistently reported few opportunities to maintain hobbies, interests or activity. The management team accepted that this needed improvement.
“We received consistent feedback from people and relatives that there were limited opportunities for being supported to maintain their hobbies and interests or to keep active.” from the report
Weak management checks
seriousAudits and the home development plan had not identified important problems in staffing, care records and assessments. This led to a breach of the good governance regulation.
“We found no evidence that people had been harmed however, systems and processes for governance and quality assurance were not always effective and failed to monitor and improve the quality of care being provided to people living at the service.” from the report
- 01What has changed to make sure there are enough staff on each unit, including when agency staff cancel at short notice?
- 02How have you checked and corrected risk assessments and care plans, especially for pressure injuries, choking, diets and meal support?
- 03What is now being done to protect people's privacy and dignity when bedroom doors are open?
- 04What regular activities are available for people who are bedbound or want to maintain hobbies and interests?
- 05Who is currently responsible for the home after the registered manager left, and how are improvements under the action plan being checked?
This was an unannounced first inspection of the newly registered service and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 29 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Alexandra Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2020
Registered with the Care Quality Commission on 31 July 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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