CQC report explained · a residential care home
What the CQC found at Hallmark Alexandra Grange Luxury Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection risks were being managed, including visitors, PPE, testing, admissions, hygiene and outbreaks. The home was also meeting the COVID-19 vaccination requirement for eligible staff and visiting professionals.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2022
Inspected but not rated; inspectors found strong infection controls and safe visiting arrangements, with resources suggested to develop the approach.
This was an announced, targeted inspection on 10 February 2022. It looked at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
Inspectors found enough personal protective equipment, very clean premises and well-stocked hand hygiene points. They were assured that the home was managing visitors, testing, admissions, PPE, outbreaks and vaccinations safely.
The home was inspected but not rated. This report does not give an overall quality rating or ratings for the other four areas of care.
Clean environment
The building was very clean, with management checks taking place each day.
“All areas of the building were extremely clean. Daily walk arounds by the management team checked the cleanliness of each area in the service.” from the report
Good infection controls
Inspectors found suitable supplies, effective hygiene arrangements and audits that led to prompt action.
“Audits were completed to scrutinise infection prevention and control. The findings were taken seriously, and the management team acted promptly to respond to any areas for improvement.” from the report
Safe visiting arrangements
Visitors had their vaccination status and lateral flow test checked before entering the main building.
“The service ensured that visitors had their COVID-19 vaccination status and lateral flow test checked before entry to the main building.” from the report
Support for essential caregivers
Essential caregivers were supported to remain part of people's lives, with risk assessments and testing in place.
“Essential caregivers were promoted to be part of people's lives. Appropriate risk assessments and testing were in place.” from the report
Further development suggested
minorInspectors signposted the home to resources to develop its approach. The report does not explain what changes were needed.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What changes have you made after inspectors signposted you to resources to develop your approach?
- 02What COVID-19-related staffing pressures were present, and what effect did they have on people living here?
- 03How are visitors' vaccination status and lateral flow test results checked now?
- 04How do essential caregiver arrangements work, including the risk assessments and testing?
- 05What do your infection prevention and control audits check, and how are improvements followed up?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other areas of care or the service overall. This explanation was written from the published report of 19 February 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 2019
Rated Good overall, but inspectors found the home was not always well-led because injury and Duty of Candour records were incomplete.
This was an unannounced, planned comprehensive inspection on 25 and 26 March 2019. Inspectors spoke with people living at the home, relatives, staff and community professionals. They also observed care and activities, toured the premises and checked care, staff and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People were described as safe and well cared for. Inspectors saw kind interactions, safe medicines practice, suitable food and drink, access to healthcare and care plans that reflected people's needs.
Well-led was rated Requires Improvement. The registered manager did not always keep clear and consistent records showing that people or their representatives had been told openly about serious injuries. Inspectors also recommended improvements to the dementia-friendly environment and to accessible information.
The overall rating remained Good. The previous inspection, published in September 2016, rated all five areas Good. This inspection found that the home had improved or maintained many aspects of care, but management records needed to be more reliable.
People felt safe
People and relatives said they felt safe. Staff understood how to raise concerns and inspectors found that safeguarding concerns had been dealt with appropriately.
“People felt safe living at the service. Relatives felt their family members were kept safe.” from the report
Kind and respectful care
Inspectors observed caring interactions. People and relatives said staff were kind, respected privacy and dignity, and supported independence.
“We observed kind and friendly interactions between staff and people.” from the report
Safe medicines practice
Prescribed medicines were given at the right times by trained staff. Medicines were stored securely and checked regularly.
“People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately.” from the report
Good health support
Staff monitored changes in people's health and contacted health professionals promptly. The home worked with GPs and other services.
“We saw the care for people's health and wellbeing was proactive and organised well.” from the report
Personalised care and activities
Care plans included people's routines, preferences and interests. The home provided activities and supported relationships with relatives.
“Care plans included information that enabled the staff to monitor the well-being of the person.” from the report
Incomplete injury records
seriousFor eight serious injuries, the home could not consistently show that all required steps had been taken and recorded openly with people or their representatives.
“Whilst the registered manager and staff had an understanding about their responsibilities in relation to Duty of Candour, all steps to be taken and outcomes had not consistently been recorded.” from the report
Dementia-friendly environment
needs fixingSome signs, toilet features and guidance around the building were not easy for people with dementia to recognise. Inspectors recommended that the home seek relevant guidance.
“Not all the doors had dementia signage indicating it, for example, toilet or bathroom signs were not to the size the person with dementia would be able to recognise.” from the report
Accessible information
needs fixingThe home had some communication guidance but inspectors were not satisfied that all parts of the Accessible Information Standard were fully covered.
“We recommend the service seeks advice and guidance from a reputable source about meeting all five steps of AIS.” from the report
- 01How do you now record and explain serious injuries, and can you show how the Duty of Candour process is checked?
- 02What changes have you made to signs, toilet features and other parts of the environment for people living with dementia?
- 03How do you identify and meet each person's communication needs, including the five steps of the Accessible Information Standard?
- 04How do you make sure activities are meaningful for each person and avoid people becoming isolated?
- 05What checks are now made on staff recruitment records before someone starts work?
This was an unannounced planned comprehensive inspection covering all five key questions, with the previous overall rating having been Good in September 2016. This explanation was written from the published report of 27 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 Hallmark Alexandra Grange Luxury Care Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Hallmark Alexandra Grange Luxury Care Home →
- April 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Hallmark Alexandra Grange Luxury Care Home →
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Inspected but not ratedSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 13 April 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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