CQC report explained · a nursing home
What the CQC found at Alicia Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Alicia Nursing Home was rated Requires Improvement; inspectors found kind care but safety checks, medicines processes and management systems were not reliable enough.
Inspectors visited without notice on three days in August and September 2023. They spoke with people, relatives and staff, and checked care records, medicines, recruitment records, infection control and quality checks.
People were treated with kindness and respect. Staff supported people patiently, offered activities and helped people make choices. People and relatives gave positive feedback about the care and staff.
However, some safety risks were not properly identified or managed. Window restrictors were missing in the second building, blood glucose devices were not checked as instructed, and some medicines records were incomplete. Quality checks did not identify these problems, and the home breached Regulations 15 and 17.
The overall rating changed from Good at the previous inspection in 2017 to Requires Improvement. The provider acted immediately on some issues during and after the inspection, but CQC said it would continue to monitor the home.
Kind and respectful care
Inspectors saw staff treating people with patience and kindness. People and relatives spoke positively about the care.
“Staff were very caring towards people and talked about them with affection.” from the report
People felt safe from abuse
Staff understood how to recognise and report abuse. The report says people felt safe and safeguarding policies were in place.
“People were protected from the risk of harm and abuse and people felt safe.” from the report
Activities and independence
People had opportunities for activities, community outings and social engagement. Care plans recorded the support people needed to remain independent.
“People were given lots of opportunities for activities and engagement.” from the report
Enough staff
Rotas showed there were enough staff to support people, including people who needed one-to-one support.
“There were enough staff to support people, including where individuals received one to one support.” from the report
Good partnership working
Staff involved other professionals promptly when needed, including GPs, speech and language services and palliative care services.
“The provider had good relationships with other professionals that worked alongside the service.” from the report
Unsafe windows and equipment checks
seriousWindows in the second building could be opened wide enough for someone to climb out and fall. Blood glucose monitoring devices were not checked according to the manufacturer's instructions.
“The height of the windows posed a risk of someone accidently falling from them as they could be opened wide enough for a person to easily climb up and out.” from the report
Medicines records and practice
needs fixingSome medicines did not have opening dates recorded, and staff were unclear about expiry dates after opening. Insulin injection sites were not recorded.
“Medicines were not always managed safely. For example, some medicines did not have opening dates recorded and staff were unclear in relation to expiry dates of medicine once opened.” from the report
Weak quality monitoring
seriousThe home's audits and checklists did not identify the problems found by inspectors. Some audits were overdue or had not been completed in line with the home's policy.
“Governance processes were not always effective at ensuring the quality and safety of the service.” from the report
Limited learning from incidents
needs fixingThe home reviewed incidents, but there was limited evidence of looking for wider patterns or taking follow-up action for some incidents.
“There was no evidence of a detailed analysis over time to capture wider themes and trends” from the report
Restrictions not regularly reviewed
needs fixingSome kitchens, bedrooms and stairs were locked or gated in the second building. The provider had not regularly checked whether these restrictions were still the least restrictive options.
“The provider had not kept restrictions to people under regular review to ensure they remained the least restrictive options.” from the report
- 01What evidence can you show that all windows in the second building now have suitable restrictors and that they are checked regularly?
- 02How are blood glucose monitoring devices now calibrated and checked, and how is this recorded?
- 03How do you record medicine opening dates, expiry dates and insulin injection sites?
- 04How often are medicines, safety and quality audits completed, and who checks that identified problems are put right?
- 05Which restrictions in the second building have been removed or changed, and how are remaining restrictions reviewed as people's needs change?
This inspection looked in detail at Safe, Caring and Well-led; the report says ratings for key questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 2 November 2023 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
Inspected but not rated; inspectors found good infection-control arrangements and safe visiting during the COVID-19 pandemic.
This was an announced, targeted inspection on 14 February 2022. Inspectors checked infection prevention and control, visiting arrangements, and whether COVID-19 staffing pressures were affecting care.
Inspectors were assured that the home was using PPE safely, managing testing and admissions, and taking steps to prevent and manage infection outbreaks. Staff were observed wearing PPE correctly.
Visitors had to show a negative lateral flow test, have their temperature checked and answer screening questions. The home was visibly clean, with no bad smells, and people were supported to keep in touch with family and friends.
The service was inspected but not rated. This means the inspection did not give an overall quality rating or new ratings for the five areas of care.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections. The infection prevention and control policy was up to date.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Safe visiting
Visitors had to complete checks before entering, including a negative lateral flow test, temperature check and screening questions. Visiting arrangements were reviewed in line with government guidance.
“All visitors were required to produce a negative lateral flow COVID-19 test prior to visiting their relative or friend.” from the report
Correct PPE use
Staff and visitors had to wear PPE. Inspectors saw staff using it correctly, and the home said it had enough supplies.
“All staff were observed wearing PPE correctly during the inspection.” from the report
Clean environment
The home was visibly clean and staff cleaned frequently touched surfaces such as door handles and light switches.
“On the day of inspection, the home was visibly clean with no mal odours.” from the report
Family contact
People were supported to keep in contact with family and friends through video calls, telephone calls, window visits, a visiting pod and essential care givers.
“People had been supported to maintain contact with their family and friends during the COVID-19 pandemic through use of video and telephone calls.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection-control and visiting arrangements are in place now, and how do they compare with those inspected in February 2022?
- 02How are staffing pressures being managed, and could they affect the care or support my relative receives?
- 03How will my relative keep in contact with family if ordinary visits are restricted?
- 04What are the home's current arrangements for PPE, COVID-19 testing and managing an outbreak?
- 05When was the service last assessed across the other areas of care, including Effective, Caring, Responsive and Well-led?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not assess the other four quality areas or give an overall rating. This explanation was written from the published report of 5 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 Alicia Nursing Home
5 rated inspections over 9 years: the service has improved, from Inadequate to Requires improvement.
- November 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- November 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: GoodCaring: GoodWell-led: Good
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- April 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 5 November 2010.
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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