CQC report explained · a residential care home
What the CQC found at Alexandra House - Leicester
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors looked only at specific concerns about staffing and infection control. They found no evidence that people were at risk from the concerns raised and were assured that infection prevention arrangements were effective.
- Effective?
- Requires improvement
- This area was not assessed during this targeted inspection.
- Caring?
- Good
- This area was not assessed during this targeted inspection.
- Responsive?
- Requires improvement
- This area was not assessed during this targeted inspection.
- Well-led?
- Requires improvement
- This area was not assessed during this targeted inspection.
What inspectors found, April 2021
Inspected but not rated; inspectors found good infection control and no evidence that people were put at risk by the concerns raised.
This was an unannounced, targeted inspection on 16 March 2021. It followed concerns about staff working while testing positive for COVID-19, staffing levels and infection control. The inspector reviewed information, spoke with staff and the manager, observed care in communal areas, and checked infection control policies and plans.
Inspectors found that staff who tested positive had been supported to self-isolate. They found the home was clean, PPE was available and used correctly, and people and staff were supported with regular testing. Visiting arrangements included testing, PPE and a separate visiting area that was cleaned after each visit.
The service was inspected but not rated. This means the inspection only looked at specific concerns and did not assess all five areas of care. The previous overall rating was Requires Improvement, published on 3 April 2019, and this targeted inspection did not change that rating.
COVID-19 response
The provider acted when a positive test was identified and supported staff to self-isolate. People and staff had access to regular testing.
“The provider had taken immediate action in line with current government guidance and requirements regarding COVID-19 to protect people and staff when a positive test result had been received.” from the report
Clean and protected environment
The home was clean and inspectors saw staff using PPE in line with the guidance in place at the time.
“We found people were protected from the risk of acquiring infections and the service was clean.” from the report
Visiting arrangements
The home had a separate visiting area, visitor testing and PPE. The area was cleaned after each visit.
“There was a designated area for visiting which meant visitors did not need to enter the home.” from the report
Support for people needing isolation
Staff had considered how to support people who might not understand social distancing or isolation, including through increased supervision and room sensors.
“Staff had given thought to how they could support people who were unable to understand social distancing and isolation, including increased supervision and the use of room sensors.” from the report
Inspectors raised no specific concerns in this report.
- 01What were the staffing concerns that led to this inspection, and have they now been resolved?
- 02What happens when a member of staff tests positive for COVID-19 or another infection?
- 03How are visitors currently tested, protected and kept separate from people living in the home?
- 04What did the last comprehensive inspection find about the areas not covered by this targeted inspection?
- 05When will the next comprehensive inspection take place, and what improvements have been made since the previous Requires Improvement rating?
This was a targeted inspection of specific staffing and infection control concerns; it did not assess all five key questions, so the previous ratings were not changed. This explanation was written from the published report of 22 April 2021 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 2019
Alexandra House - Leicester was rated Requires Improvement; inspectors found kind care but important gaps in safety, personalised support and management.
This was the home's first comprehensive inspection. It was unannounced and took place on 17 January 2019. Inspectors spoke with people and a relative, observed care and medicines, reviewed care records and examined staffing, safety and management records.
People said they felt safe and there were enough staff. However, emergency evacuation plans were incomplete, food safety checks were not always followed and one fridge thermometer was not working. Medicines were generally managed safely, but advice was needed about giving one medicine disguised in food.
Staff were kind, respectful and knew people well. The home provided healthcare support, training and a clean environment. However, dementia-friendly signs, person-centred care plans, activities, end of life planning and mental capacity records needed improvement.
The overall rating was Requires Improvement. The five ratings were Requires Improvement for Safe, Effective, Responsive and Well-led, and Good for Caring. The report says there was an increased risk that people could be harmed, although the manager was taking steps to improve the home.
Kind and respectful staff
Inspectors found that staff knew people well and treated them kindly. People's privacy, dignity and independence were protected.
“People were cared for by staff who knew them well, were kind and caring.” from the report
Clean home
The building was clean and cleaning schedules showed that regular cleaning took place. Laundry procedures were also used to reduce cross-contamination.
“We saw a high standard of cleanliness throughout the building and cleaning schedules showed that regular cleaning took place.” from the report
Staff training and support
Staff received training, induction and supervision. Extra support was provided when staff needed more time to become confident.
“Staff received suitable training to ensure they had the skills to do their job.” from the report
Regular risk reviews
Risk assessments were reviewed when people's needs changed. Staffing levels and recruitment checks were considered sufficient.
“Risk assessments were reviewed and updated regularly or when people's needs changed.” from the report
Emergency evacuation plans
seriousNot everyone had a personalised emergency evacuation plan. The quick reference plan also needed improvement so people could leave quickly and in an organised way.
“Not all people had personalised emergency evacuation plans (PEEP's) in place.” from the report
Food safety checks
seriousFood storage procedures were not always followed. Fridge temperatures were not recorded accurately, high readings were not reported and one fridge had no working thermometer.
“Systems were in place for storing food appropriately including food coverings and date labels, but we saw that this system was not always used.” from the report
Personalised care records
needs fixingCare plans did not consistently give staff clear guidance about how each person wanted to be supported. People's representatives were not always shown to be involved in reviews.
“Care plans were not consistently person centred and did not give staff clear guidance on how the person would want to be supported.” from the report
End of life wishes
needs fixingPeople's wishes for end of life care had not been formally recorded. This meant staff could not be sure they were following each person's choices.
“People's end of life wishes had not been formally documented.” from the report
Mental capacity records
needs fixingCapacity assessments were too general and did not clearly record which decisions people could make. Records did not show how best-interest decisions had been made or who was involved.
“Mental capacity assessments were generalised and did not detail specific decisions that people could or couldn't make for themselves.” from the report
- 01Have every person's personalised emergency evacuation plan now been completed, and has the quick reference evacuation plan been improved?
- 02How are food storage rules and fridge temperatures checked now, and how are high readings acted on?
- 03How do current care plans record each person's history, culture, religion, lifestyle, preferences and end of life wishes?
- 04What dementia-friendly signs and activities are now available, especially for people who may become confused or need help with orientation?
- 05How are mental capacity assessments and best-interest decisions recorded, including who was involved?
This was an unannounced first comprehensive inspection covering all five key questions and the care home premises and care provided. This explanation was written from the published report of 3 April 2019 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 House - Leicester
Each visit the CQC has published, newest first, back to the day the home was registered.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 23 November 2017.
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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