CQC report explained · a residential care home
What the CQC found at Alexandra Villa
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2019
Rated Good; inspectors found safe, kind and person-centred care, with improvements needed to the lounge and auditing.
This was a planned, announced inspection on 05 November 2019 and 11 November 2019. One inspector spoke with the one person living at the home, five staff members and one professional. They also reviewed care, medicine, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that staff understood risks, medicines were managed safely, staff were trained and the person received kind, respectful and personalised support.
The lounge was clean but did not feel homely. Rain noise from its conservatory-style roof affected its use, and the report recommended improving the environment. The provider had also introduced a new auditing process, but this needed further development.
The previous inspection rating was Good, published on 4 May 2017, and all five ratings remained Good. CQC said it would continue monitoring information about the home and inspect again through its normal programme, or sooner if concerns were received.
Understanding risks
Staff understood how to keep the person safe and reduce risks. Safety checks and fire drills were carried out.
“The registered manager and the staff understood how to keep the person safe.” from the report
Staff support and training
Staff received induction, supervision and training, with an online programme available to keep their knowledge up to date.
“Staff were supported through a programme of induction, supervision and training.” from the report
Kind and respectful care
Staff knew the person's preferences and promoted their emotional wellbeing, privacy, dignity and independence.
“The person using the service was well-treated by staff who knew their likes and dislikes and promoted their emotional well-being.” from the report
Personalised support
Care plans covered important aspects of the person's life and staff supported daily choices, activities and communication.
“Care plans covered a range of topics which were important to the person.” from the report
Positive culture
Inspectors found consistent care and supportive management. Staff said they could approach the manager with confidence.
“The staff team had developed a positive culture in which they delivered consistent care.” from the report
Lounge was not homely
needs fixingThe lounge lacked homeliness. Water had previously entered through the roof, and heavy rain made the noise distracting when using the room.
“We recommend steps be taken to provide an improved homely environment.” from the report
Auditing process still developing
needs fixingA new provider auditing tool had been introduced, but it was at an early stage and needed more implementation to demonstrate continuous improvement.
“The new type of auditing was in the early stages of development and required further implementation to demonstrate continuous improvements.” from the report
One missing reference
minorOne staff recruitment file did not contain a second reference when checked. The manager obtained it during the inspection.
“On checking records we found one staff member did not have a second reference.” from the report
- 01What changes have been made to make the lounge more homely and reduce the impact of rain noise?
- 02How has the new auditing process developed since the inspection?
- 03How do you check that every staff member has the required recruitment references before starting?
- 04How will you support the person to keep developing independence and taking part in community activities?
- 05How are the person's complaints, worries and choices recorded and followed up?
This was a planned inspection of the care home, including both the premises and the care provided, and all five CQC questions were rated. This explanation was written from the published report of 3 December 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.
What inspectors found, May 2017
Rated Good; inspectors found safe, kind and personalised care, with some gaps in recording staff support and care plan reviews.
This was an announced inspection on 14 March 2017. Inspectors spoke with the person using the service, two staff members and an external healthcare professional. They reviewed care and medicine records, staff files, safeguarding and complaints records, meeting minutes and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine arrangements, thorough recruitment checks and care plans that reflected the person's needs, choices and independence.
Staff were described as kind and knowledgeable. The person was supported with activities, food, healthcare and community involvement. The home had improved since earlier inspections, when four legal breaches had been found, and previous required actions had been completed.
Inspectors still recommended better record keeping. Supervision was not always formally recorded, some induction records were not signed off, and recent care plan reviews had not been signed by the person. Unsecured ladders were also found during the visit and were to be removed.
Caring relationships
Staff had built strong relationships with the person and understood their individual needs, likes and dislikes.
“Staff had developed strong, caring relationships with the people they supported and were very knowledgeable about their individual needs, likes and dislikes.” from the report
Personalised care
Care plans were detailed and person-centred. The person and their representatives were involved in planning and reviewing support.
“Detailed, person-centred care plans were produced which guided staff on how to care for people.” from the report
Safety and staffing
Inspectors found adequate staffing, suitable on-call support and robust recruitment checks.
“The registered provider had now recruited adequate staff to ensure the service had its required compliment.” from the report
Improvement since earlier inspections
The home had acted on previous inspection findings and improved its checks and leadership arrangements.
“Actions required from previous inspections had now all been completed.” from the report
Supervision records
needs fixingStaff supervision was not always recorded in line with the provider's policy. The provider said supervision was now in place and timetabled.
“We recommend the registered person ensure that staff receive regular and documented supervision in line with their policy.” from the report
Care plan signatures
needs fixingRecent care plan reviews had not been signed and agreed by the person, although staff said the person had been involved.
“We noted that recent reviews to the persons care plan had not been signed and consented to by the person.” from the report
Unsecured ladders
minorInspectors saw unsecured ladders during the visit. The covering manager agreed to remove them when this was raised.
“During the inspection we noted some unsecured ladders, when we drew this to the covering manager's attention they agreed to remove them.” from the report
- 01How are staff supervision sessions now recorded, and how do you check they follow the provider's policy?
- 02How do you make sure care plan reviews are signed and agreed by the person?
- 03What checks are carried out to identify and remove hazards such as unsecured ladders?
- 04How will staffing and 24-hour on-call support be maintained when staff are absent?
- 05What evidence can you show that the improvements made after the earlier inspections have been maintained?
This announced inspection considered the overall service and all five rating areas, using evidence from one person using the home, two staff members, an external healthcare professional and selected records. This explanation was written from the published report of 4 May 2017 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 Villa
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- December 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 5 June 2011.
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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48 live-in carers within about an hour of Gateshead
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,240 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.