CQC report explained · a nursing home
What the CQC found at Alexandra Nursing & Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Alexandra Nursing & Residential Home was rated Good; inspectors found safe care and stronger management after previous concerns.
This was an unannounced focused inspection on 10 November 2022. Inspectors spoke with 11 people living in the home, two relatives and 23 staff. They observed care and checked care plans, medicines records, staff files, audits, policies and safeguarding records.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse and avoidable harm, medicines were managed safely, staffing levels met people's needs, and infection risks were well managed.
The inspection followed a previous Requires Improvement rating and a breach about governance. Inspectors found enough improvement had been made and the home was no longer in breach. The overall rating changed to Good.
This inspection only assessed Safe and Well-led. The other key question ratings were carried forward from the previous inspection.
Safe staffing
Inspectors found staff had been recruited safely and that there were enough staff to meet people's needs.
“We observed there were sufficient staff available to meet people's needs.” from the report
Medicines
Medicines records, controlled drug records, storage and disposal arrangements were checked and found to be managed safely.
“Medicines were managed safely and effectively.” from the report
Learning from incidents
The home recorded and reviewed accidents and incidents, and took action to reduce the chance of problems happening again.
“There was evidence improvements had been made in relation to the security of the home following a recent incident.” from the report
Better governance
The provider had improved its systems for monitoring quality and was no longer in breach of the governance regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 17.” from the report
Visiting arrangements
minorAt the time of the inspection, relatives had to make an appointment before visiting. The registered manager acted afterwards so that visiting times were not restricted.
“At the time of our inspection, relatives were required to make an appointment prior to visiting the home.” from the report
- 01How have you maintained the improvements made after the previous breach of Regulation 17?
- 02Can relatives visit freely now, without restricted visiting times?
- 03How do you check that staffing levels continue to meet each person's needs?
- 04How are medicines audits and controlled drug checks carried out and followed up?
- 05How are people and relatives involved in meetings and decisions about the home?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 December 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, March 2022
Rated Requires Improvement; this targeted inspection found good infection control and visiting arrangements, but did not rate the service as safe.
Inspectors visited on 25 February 2022. This was an announced, targeted inspection focused on infection prevention and control during the COVID-19 pandemic. They also asked about staffing pressures.
The inspectors were assured that the home was using personal protective equipment safely, arranging testing, managing visitors and admissions, and keeping its infection control policy up to date. They also found enhanced cleaning of frequently touched areas and a nightly deep clean.
Staff knew people well and supported their wellbeing. Activities and video calls helped reduce isolation and keep people in touch with relatives. Visitors were welcome and risk assessments supported visits.
The overall rating was Requires Improvement. Safe was inspected but not rated, and this report gives no ratings for the other four questions. It does not explain which specific area led to the overall rating.
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including safe PPE use, testing and cleaning.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Cleanliness
Frequently touched areas were cleaned on an enhanced schedule, with a deep clean every night.
“An enhanced cleaning schedule of high touch areas was in place and a deep clean was conducted nightly.” from the report
Support for wellbeing
Staff knew people well and supported activities and video calls to reduce isolation during the pandemic.
“Staff encouraged people to participate in activities to reduce feelings of isolation, and facilitated video calling for people to stay in touch with their loved ones.” from the report
Visiting
Visitors were welcomed, given PPE and asked to take a lateral flow test. Risk assessments supported people spending time with relatives.
“All visitors to the service were required to complete a lateral flow test prior to accessing the home, and were provided with appropriate PPE.” from the report
Overall rating
needs fixingThe home was rated Requires Improvement overall. This report does not explain what specific shortfall led to that rating, so families should ask what needs to improve.
“Overall rating for this service Requires Improvement Is the service safe? Inspected but not rated” from the report
- 01Why was the home rated Requires Improvement overall, and what improvements are being made?
- 02How did COVID-19-related staffing pressures affect people living at the home?
- 03Are the testing, PPE, cleaning and infection control arrangements described in the report still in place?
- 04How are visits arranged now, including visits from essential care givers?
- 05How will the home help residents keep in touch with relatives if there is another outbreak?
This was an announced targeted inspection of infection prevention and control and staffing pressures; Safe was inspected but not rated, and the other four questions were not rated in this report. This explanation was written from the published report of 12 March 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 Nursing & Residential Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Alexandra Nursing & Residential Home →
- March 2022Requires improvementstayed Requires improvementSafe: Inspected but not rated
Read what inspectors found at Alexandra Nursing & Residential Home →
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015
Registered with the Care Quality Commission on 29 December 2015.
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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