Archived: Alexandria's Residential Care Home

At the last inspection on 11 January 2018 we rated the service Requires Improvement overall. The service remained rated as Inadequate in well led, which meant the service remained in special measures. We found breaches of Regulations 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach of section 33 of the Health and Social Care Act 2008. The provider had failed to operate effective recruitment procedures.

The provider needed to make further improvements to ensure the premises and equipment were suitably maintained, appropriately located and clean. The provider had failed to ensure that medicines were suitably stored according to the manufacturer’s instructions. The provider had failed to provide training and support for staff relating to people's needs. The provider had failed to operate effective quality monitoring systems. The service did not have a registered manager. The provider had failed to apply to register with CQC the manager they had employed.

We served the provider a warning notice for the breach of Regulation 12 and told the provider to meet this Regulation by 20 March 2018. We also served the provider a warning notice for the breach of Regulation 15 and told the provider to meet this by 03 April 2018. We served the provider a fixed penalty notice for having no registered manager in post. We imposed a condition of registration in relation to the breach of Regulation 17 and served the provider requirement actions relating to the breaches of Regulations 18 and 19. We also made recommendations. We recommended that the provider reviewed systems and processes to evidence that staffing levels met people’s assessed needs. We recommended that the provider reviewed and amended practice at meals times to ensure that reasonable adjustments were made to meet people’s nutritional needs and preferences taking into account people’s communication preferences. We recommended that the provider reviewed practice to ensure that people received the care and support according to their wishes and preferences. We recommended that that provider sought guidance from a reputable source to review and amend policies, procedures and documentation to ensure people’s equality diversity and human rights (EDHR) needs were met. We also recommended that the provider reviewed the complaints information to ensure that it was in an accessible format to meet the needs of people living in the service.

The provider did not submit an action plan within agreed timescales and was formally chased for this by letter. The provider submitted documentation to detail that they had met the warning notices. Following the last inspection, we met with one of the providers to discuss our concerns about the ongoing non-compliance with regulations and to ask the provider to complete an action plan to show what they would do and by when to meet the regulations under each of the five. An action plan was received eventually on 25 April 2018.

Alexandria's Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service was not registered to provide nursing care. Any nursing care was provided by community nurses.

At the time of our inspection 10 people lived at the service. There was a through floor lift fitted in the home to enable people to use the first floor. There were a small number of bedrooms on the second floor which were accessible using a stair lift, these rooms were not in use. The service accommodated up to 18 older people. Some people lived with dementia.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was in breach of their registration by not having a registered manager in post.

Medicines had not been managed effectively. Medicines records were not complete; stock had not always been counted and recorded appropriately. Medicines were securely stored. Some storage areas had not been temperature checked the ensure that medicines were being stored at safe temperatures. We reported this to the local authority.

There were enough staff deployed on shift to meet people's care and support needs. The provider had reduced staffing levels. One staff member had been removed from the morning shift and one staff member had been removed from the afternoon shift. The housekeeper’s hours had also been cut back. The provider had not carried out an assessment of people’s care and support needs when reviewing staffing levels.

The provider did not follow safe recruitment practices. Essential documentation was not available for all staff employed. Gaps in employment history had not been explored to check staff suitability for their role.

Risks to people's safety and wellbeing were not always managed effectively to make sure they were protected from harm. Risk assessments had not always been reviewed and updated when people's health needs changed. The provider had failed to take action when accidents and incidents had occurred. Lessons had not been learnt from accidents and incidents to prevent further concerns and to strive for improvement.

Staff had a good understanding of what their roles and responsibilities were in preventing abuse.

Several areas of the home smelt of stale urine. The home was dirty and required redecoration and maintenance. Fire drills had not taken place within six months as detailed in the provider’s policy. The emergency evacuation chair was not easy to get to as the medicines trolley was fixed the wall in front of it.

Decoration of the home did not follow good practice guidelines for supporting people who lived with dementia.

Staff had not received all the training, support and supervision they needed to meet people’s assessed needs. The provider had not followed good practice guidance to ensure that new staff received a comprehensive induction.

People’s healthcare needs had been met in a timely manner. People who were at risk from developing pressure areas had been referred to community nurses and were supported to reposition regularly. Barrier creams and sprays had consistently been used to protect people’s skin.

The provider did not have good systems in place to monitor the quality and safety of the service provided. The provider had no evidence to show they had undertaken quality audits. Accurate records were not kept to ensure good communication and the safety of people being supported.

The provider did not offer staff the support and help they required. Staff meetings had not been held.

The provider had failed to notify CQC of important events such as deaths and safeguarding allegations.

People were treated with dignity and respect by the staff. Staff respected people's privacy. Staff were kind and caring towards people and offered plenty of reassurance. However, the provider had failed to treat people in a kind and caring manner and had failed to treat people with dignity and respect.

People were not provided with sufficient, meaningful activities to promote their wellbeing.

People’s care plans detailed their care and support needs. Staff knew people well and provided personalised care. Some people had not had baths or showers for some time.

People had not had opportunities to voice their views and opinions about the service through surveys and through meetings.

The provider's complaints procedure did not give people all the information about who they could raise concerns with. There was no accessible and easy to understand complaints information in place. The provider had not followed their complaints policy.

People had choices of food at each meal time. People were offered more food if they wanted it. Food choice was restricted to chicken or pork/gammon. Food stocks were low and staff were purchasing food to ensure people had choices.

There were procedures in place and guidance was clear in relation to the Mental Capacity Act 2005 (MCA) that included steps that staff should take to comply with legal requirements. Staff had a good understanding of the MCA 2005 to enable them to protect people’s rights.

The provider did not have an understanding of when people’s Deprivation of Liberty Safeguards (DoLS) authorisations had expired, no action had been taken to reapply to legally deprive people of their liberty.

Staff working in the kitchen were unable to follow ‘Safer Food Better Business’ guidance provided by the Food Standards Agency. We reported this to the Food Standards Agency.

People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were welcomed at the service at any reasonable time.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a number of breaches of the Care Quality Commission (Registration) Regulations 2009 . You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Inadequate’ and therefore the service remains in ‘Special measures’. This is the third consecutive time the service has been in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant im

At the previous inspection on the 06 and 20 June 2017 the service was rated Inadequate. The provider had breached Regulations 9, 10, 12, 13, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. The provider had also breached Regulation 18 Registration Regulations 2009. They had not notified CQC about important events such as Deprivation of Liberty Safeguards (DoLS) authorisations and safeguarding events that had occurred. The service was placed into special measures.

After the inspection the provider submitted representations against proposed action on 15 August 2017 which detailed how they had started to improve the service and what further action they were taking to make improvements.

Alexandria's Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service was not registered to provide nursing care. Any nursing care was provided by community nurses.

At the time of our inspection 16 people lived at the service. There was a through floor lift fitted in the home to enable people to use the first floor. A small number of bedrooms were on the second floor which were accessible using a stair lift. The service accommodated up to 18 older people. Some people lived with dementia.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was in breach of their registration by not having a registered manager in post. There was a manager in post, they were about to start the process of applying to become a registered manager. However, shortly after the inspection they left the service.

Although people and their relatives gave us positive feedback about the service, we found that the provider had not made sufficient improvements.

The provider had not always followed effective recruitment procedures to check that potential staff employed were of good character and had the skills and experience needed to carry out their roles.

Although the service had undergone some redecoration and maintenance. Maintenance records evidenced that repairs and tasks were not always completed quickly. Food and cleaning chemicals had been stored together in an upstairs store room. There were a number of areas upstairs in the service which smelt of urine. Other areas of the home were clean and tidy.

Medicines were administered safely. People received their prescribed medicines at the right times. Medicines were not always stored at the correct temperature. Records showed that the storage areas were consistently above the manufacturer’s safe maximum temperature.

Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service.

Staff had not always received training relevant to their roles. Some staff had received supervision and support from the manager; others had been in post for some time without supervision.

There were enough staff available to meet people’s needs. However, there was no clear record of how staffing levels had been assessed and deployed. We made a recommendation about this.

People’s care was person centred. Care plans detailed people’s important information such as their life history and personal history and what people can do for themselves. People were supported to be as independent as possible. People’s care records did not always detail that they had shaves as frequently as they had wanted. We made a recommendation about this.

The providers assessment process required amending and updating to ensure it captured people’s needs in relation to equality, diversity and human rights. We made a recommendation about this.

People and their relatives knew who to talk to if they were unhappy about the service. No complaints had been received. The complaints information was not available to people in different formats or accessible versions to help them understand the information. We made a recommendation about this.

Risk assessments were in place to mitigate the risk of harm to people and staff.

Staff knew and understood how to protect people from abuse and harm and keep them safe.

People did not always have choices of food at each meal time. We made a recommendation about this. People had adequate fluids to keep themselves hydrated.

The provider had started to improve the home and had made a start on improving the signage to help people find their way around and find their own bedrooms. Further improvements were required; there were no signs in the communal lounge, or the dining area to help people find their way to other areas of the home such as the lift or bathrooms and toilets.

People were supported and helped to maintain their health and to access health services when they needed them.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People were not deprived of their liberty, so no applications had been made.

Staff were cheerful, kind and patient in their approach and had a good rapport with people. The atmosphere in the service was calm and relaxed. Staff treated people with dignity and respect.

People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were welcomed at the service at any reasonable time.

People and their relatives did not have a formal means of providing feedback about the service they received. They had not been sent surveys and meetings had not taken place. Compliments had been received from relatives in the form of thank you cards.

Relatives and staff told us that the service was well run. Staff were positive about the support they received from the manager. They felt they could raise concerns and they would be listened to.

The manager demonstrated that they had a good understanding of their role and responsibilities in relation to notifying CQC about important events such as injuries, safeguarding concerns and deaths.

After the last inspection the service was placed into special measures. Although the overall rating for this service is ‘Requires improvement’. We are leaving the service in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of section 33 of the Health and Social Care Act 2008. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Alexandria's Residential Care Home is a care home providing personal care and accommodation for up to 18 older people. Some were older people living with dementia, some had mobility difficulties and sensory impairments. Accommodation is arranged over three floors. There is a lift in place to enable people to access the first floor. There is a stair lift in place on the first floor to access bedrooms and a bathroom on the top floor. There were 17 people living at the home during our inspection.

At the time of the inspection registered manager had left the service, they were in the process of cancelling their registration. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The provider had employed a new manager who had not started their role on the first day of our inspection, but was in post on our second day of inspection. The new manager was in the process of applying to become the registered manager.

At this inspection people gave us mixed feedback about the service they received. People told us they felt safe and well looked after. However, our own observations and the records we looked at did not always match the positive descriptions people had given us. Most of the relatives who we spoke with during our visit were satisfied with the service.

Medicines had not been administered, recorded, stored or monitored effectively. People had not received medicines that had been prescribed for them which put them at risk of harm. We reported this to the local authority safeguarding team.

There was not enough staff deployed to meet people's care and support needs. The provider did not have an effective system to assess how many staff were required to meet people's needs and to arrange for enough staff to be on duty at all times.

The provider did not follow safe recruitment practices. Essential documentation was not available for all staff employed. Gaps in employment history had not been explored to check staff suitability for their role.

Risks to people's safety and wellbeing were not always managed effectively to make sure they were protected from harm. Risk assessments had not always been reviewed and updated when people's health needs changed.

Staff had a good understanding of what their roles and responsibilities were in preventing abuse. The safeguarding policy did not give staff all of the information they needed to report safeguarding concerns to external agencies.

Fire escape routes were not suitable for people living in the home, one fire escape was blocked with a chair, and items had been stored in the stair well. We reported our concerns to the fire service.

Several areas of the home smelt of stale urine. The home was dirty and required redecoration and maintenance to meet a satisfactory standard.

Decoration of the home did not follow good practice guidelines for supporting people who lived with dementia.

Staff had not received all the training they needed to meet people’s assessed needs. The provider had not followed good practice guidance to ensure that new staff received a comprehensive induction.

People’s healthcare needs had not always been met in a timely manner which had led to delays in receiving treatment for pressure ulcers placing them at harm of further skin damage.

The provider did not have good systems in place to monitor the quality and safety of the service provided. The provider had undertaken quality audits in some areas but these had not been robust enough to capture the action required to improve the service. None of the issues we found during our inspection had been picked up by the provider. Lessons had not been learnt from accidents and incidents in order to prevent further concerns and to strive for improvement.

Accurate records were not kept to ensure good communication and the safety of people being supported.

People were not always treated with dignity and respect because people were not always spoken with in a pleasant manner. Staff did not always respect people's privacy, staff entered people’s bedrooms without knocking first. Care records were not stored securely to maintain confidentiality.

People were not always provided with personalised care. They were not provided with sufficient, meaningful activities to promote their wellbeing.

People had opportunities to voice their views and opinions about the service through surveys and through meetings. However, their views had not always been taken into account to make improvements.

The provider's complaints procedure did not give people all of the information about who they could raise concerns with. We made a recommendation about this.

Staff had received regular supervision with their line manager and felt confident that they could raise issues at staff meetings.

People had choices of food at each meal time. People were offered more food if they wanted it.

There were procedures in place and guidance was clear in relation to the Mental Capacity Act 2005 (MCA) that included steps that staff should take to comply with legal requirements. Staff had a good understanding of the MCA 2005 to enable them to protect people’s rights.

People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were welcomed at the service at any reasonable time.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

There was a new manager in post who had applied to be registered with the Care Quality Commission (CQC) and their application was in progress. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in October 2015, we had identified breaches in regulations and had requested the provider to take action regarding: staffing levels and the quality monitoring systems including records. We also identified shortfalls and had made recommendations in the management of accidents and incidents; the emergency contingency plan; infection control; staff induction, training and supervision; the personalisation of care plans; the involvement of people and staff in the running of the service. At this inspection we checked that remedial actions had been taken and we found that all necessary improvements had been implemented.

Staff knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

There was a sufficient number of staff deployed to meet people’s needs. Thorough recruitment procedures in place which included the checking of references. Staff received essential training, additional training relevant to people’s individual needs, and regular one to one supervision sessions.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

Staff knew each person well and understood how to meet their support and communication needs. Staff communicated effectively with people and treated them with kindness and respect.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There was a system in place to assess people’s mental capacity and appropriate applications to restrict people’s freedom had been submitted to the DoLS office as per legal requirements. The manager had considered the least restrictive options for each individual and was in the process of submitting more applications.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People told us they enjoyed the food. Staff knew about and provided for people’s dietary preferences and restrictions.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, life history, likes and dislikes and preferred activities. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

Some activities were provided to people that were suitable for people living with dementia. However these were provided by care staff until an activities coordinator could be recruited. The manager had plans to improve the provision of activities at the home. We have made a recommendation about this.

Staff told us they felt supported by the manager and the provider. The manager was open and transparent in their approach. They placed emphasis on continuous improvement of the service.

There was a system of monitoring checks and audits to identify any improvements that needed to be made. The manager acted on the results of these checks to improve the quality of the service and care.

We found people were respected and involved in their care and treatment. We noted staff interactions with people were positive and people seemed at ease and relaxed in the home. A relative of a person who used the service told us they found the home had a 'friendly atmosphere and it felt welcoming'.

We saw people had been involved in their plan of care, but found concerns that people's daily routines had not always been included.

We found the service had completed risk assessments for people who lived in the home to help staff maintain people's safety and wellbeing, but were concerned these were not reviewed following incidents, to minimise the risk of future incidents.

We also found that although appropriate arrangements had been made for the obtaining, safe keeping and disposal of medicines, the provider was not ensuring people who used the service were receiving all of their prescribed medication in a safe way by failing to maintain accurate records of what medication had been given to them.

We saw people who used the service were not protected from unsafe or inappropriate care and treatment because accurate and up to date records were not being maintained.