The inspection took place on 20 July 2017 and was unannounced. At our last inspection on 20 April 2015, the service was found to be meeting the required standards in the areas we looked at. Alexandra Care Home provides residential and nursing care for up to 76 elderly people who may live with dementia. At the time of our inspection 74 people were living at the home.

There was a manager in post who had registered with the Care Quality Commission (CQC). 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 and associated Regulations about how the service is run.

People were supported to take their medicines by trained staff. However these medicines were not consistently dispensed safely. Medicine audits had not identified the issues found. However the registered manager took immediate action.

People felt safe at Alexandra Care Home. Staff had received training in how to safeguard people from abuse and knew how to report concerns, both internally and externally.

Safe recruitment practices were followed to help ensure that all staff were suitably qualified and experienced. Arrangements were in place to ensure there were sufficient numbers of suitable staff available at all times to meet people’s needs.

Where potential risks were identified there was involvement of other professionals to help ensure people were safe.

Staff received training and refresher updates relevant to their roles and had regular supervision meetings to discuss and review their development and performance.

People were supported to maintain good health and had access to health and social care professionals when necessary. People were provided with a healthy balanced diet that met their individual needs.

Staff obtained people’s consent before providing personal care and support, which they did in a kind and compassionate way. Staff had developed positive and caring relationships with the people they cared for.

People were involved in the planning, delivery and reviews of the care and support provided. Confidentiality of information held about people’s medical and personal histories was securely maintained throughout the home.

People received personalised care and support that met their needs and took account of their preferences. Staff were knowledgeable about people’s background histories, preferences, routines and personal circumstances.

People were supported to take part in meaningful activities relevant to their needs.

Complaints were recorded and responded to in line with the service policy. People, relatives and staff were complimentary about the registered manager and how the home was run and operated.

This inspection took place on 20 April 2015 and it was unannounced. The service provides accommodation for up to 76 older people who require nursing or personal care, some of whom may be living with dementia. On the day of the inspection, there were 70 people living in the home.

The service has 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.

There were systems in place to safeguard people from the risk of possible harm. Risks to individuals had been assessed and managed appropriately. There were sufficient numbers of trained, experienced and skilled staff to care for people safely. There was an effective recruitment process in place. Medicines were managed safely and people received their medicines, regularly and as prescribed.

Staff understood their roles and responsibilities to support people appropriately and to seek their consent before providing care. They received regular supervision and support and were aware of people’s individual needs.

People were treated with respect, kindness and compassion and they had been involved in the decisions about their care. They were supported to access other health and social care services when required.

People’s health care needs were assessed, reviewed and delivered in a way that promoted their wellbeing. An effective complaints procedure was in place.

There was a formal process for handling complaints and concerns. The provider had effective quality monitoring processes in place.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014.

This inspection was unannounced.

Alexandra Care Home provides both residential and nursing care for up to 76 people, some of who may live with dementia. At the time of our inspection the home had a manager in post who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

The staff team at Alexandra Care Home were not all aware of people’s needs and able to respond to these in an individual manner. However, we also found that there had been an increased staff turnover and relatives told us this had impacted on the service. The registered manager was aware of these issues and had recently recruited a number of staff. However people we spoke with told us that there were still at times insufficient staffing numbers to meet their needs. This meant they had breached regulation 22 of the Health and Social Care Act 2008 because they had failed to ensure sufficient numbers of staff were available to support people. You can see what action we told the provider to take at the back of the full version of this report.

Care plans were being reviewed regularly and the home was in the process of implementing a new personalised system for care planning. Peoples care needs were recorded and staff we spoke with were aware of people’s individual needs and wishes. We observed staff being kind and supportive. People and their relatives told us that staff were caring.

There was a quality assurance system in place. The manager carried out regular audits and developed action plans. This was reviewed by the regional manager and discussed with the provider. Complaints were responded to appropriately.

Staff we spoke with were aware of how to keep people who lived at Alexandra Care Home safe. People who lived there and their relatives told us they felt safe and cared for. There were policies in place that identified how staff were able to report their concerns about possible acts of abuse.

Staff we spoke with told us that they were aware of the signs of abuse and how this was to be reported. However we also spoke with one person who had received poor care and did not feel safe.

This meant they had breached regulation 11 of the Health and Social Care Act 2008 because they had failed to respond to an act of suspected abuse and had failed to report this. You can see what action we told the provider to take at the back of the full version of this report.

The service had regular meetings for staff, people and their relatives. There were annual surveys sent out to people and their relatives to gain their views.

The provider acted in accordance with the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS). The provisions of the MCA are used to protect people who might not be able to make informed decisions on their own about the care or treatment they receive.

Food was not maintained at a safe temperature and people received meals that were cold. This meant they had breached regulation 14 of the Health and Social Care Act 2008 because they had failed to ensure that people were protected from the risks of inadequate nutrition. You can see what action we told the provider to take at the back of the full version of this report.

People were not always treated in a manner which promoted their dignity and respect and respected their privacy when assisting them with eating their meals. This meant they had breached regulation 17 of the Health and Social Care Act 2008 because they had not ensure people were treated in a dignified manner when assistance was provided.

The manager completed regular audits from a planned schedule, and then where necessary they developed action plans and reported their findings to the regional manager.

The provider failed to send to the Commission, when requested to do so, a written report in relation to the management of home. This meant they had breached regulation 10 of the Health and Social Care Act 2008 because they had not sent to the commission when requested a report of how they provider felt they met the regulations.

Our inspector gathered evidence to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found based on the evidence gathered during our inspection carried out on 27 May 2014. This included speaking with people who used the service, their relatives and members of staff who supported them. We looked at people's care records.

Is it safe?

We noted that call bells were within people’s reach so they were able to request help and support if they needed it.

People told us that they were happy at the home and that staff were kind and attentive. People said that they felt able to raise their concerns. One person told us, "Yes I feel safe here now. The new manager has brought in new staff and they are really kind and supportive."

Staff we spoke with were able to demonstrate their awareness, through discussion, of the signs of abuse, and told us how they would report their concerns. Staff had received training in relation to safeguarding adults from abuse.

Is the service effective?

We saw that assessments had been completed and reviewed in relation to a wide range of issues relevant to people’s care needs. These included assessments which related to the management of people’s medicines, skin integrity and risks associated with pressure care, nutrition and hydration, mobility and falls.

During our inspection we did not see that any meaningful activity took place for people who used the service.

Where people displayed challenging behaviour there was no effective care planning to address how this was to be managed.

People’s weight and nutritional needs were regularly assessed. Where a person was at risk of malnutrition or dehydration staff members took appropriate action.

We found that there was enough experienced staff available to support people’s needs. Care was provided in a timely manner and call bells were answered promptly.

The manager had recently implemented a new system to encourage people who lived with dementia to choose a meal. They were shown a choice of two meals to assist them just prior to the meal being served. This helped to ensure that people were aware of their menu choices.

However people were not always provided with food that was in line with the recommendations of a dietician.

Is the service caring?

During our inspection we saw that people who lived at the home were treated with care and respect.

We observed the breakfast and lunchtime meals and saw that staff members provided appropriate levels of support to help people to eat and drink in a calm, patient and dignified manner. This promoted their independence.

We observed that staff interacted with people with warmth and respect. For example, we watched as a staff member assisted a person to transfer from their wheelchair to an armchair. We noted they provided continuous re-assurance to the person, maintained their dignity at all times, and ensured they were comfortable and secure.

Staff members we spoke with were able to demonstrate a comprehensive understanding of people’s needs.

Is the service responsive?

We saw that people’s views, experiences and choices were considered in the way that care, support and treatment was delivered. The provider had collated people's views and experiences through surveys and meetings. These included people who used the service, and their relatives. We noted that people were generally satisfied with the care that they received.

Where people were at risk of dehydration or malnutrition, they were referred appropriately for specialist support from health professionals such as doctors or dieticians. We saw the recommendations were then followed, and regular checks of people's weight, nutrition, fluid intake, skin integrity and general wellbeing were carried out.

Where people were at risk of developing pressure ulcers, staff members ensured the appropriate pressure relieving devices were used, such as mattresses and cushions.

Is the service well led?

We saw that people had access to relevant health care professionals where necessary including GPs, dieticians and occupational therapists.

Records we looked at showed that the home took account of accidents, incidents and near misses and investigated them thoroughly.

Effective systems were in place to assess and monitor the quality of services provided. Systems were also in place to identify, assess and manage risks posed to the health, welfare and safety of people who lived at the home.

In August 2013 following an inspection the service was found to be non-compliant in seven outcome areas. We completed a “follow up” visit in October 2013 to check that the provider had made the required improvements. We found that the home had made significant progress, however they were still found to be non-compliant in three of the outcome areas from the previous inspection.

At our most recent inspection, we found the provider had made all the required improvements and were found to be meeting all the regulation outcomes we tested. People who used the service told us that things in the home had improved over the past six months. We asked people what had improved. People told us there were more staff on duty and they were able to spend more “quality time” with people. Food and menu’s had been reviewed and people and their relatives had contributed to the process. The home had undergone major refurbishment and looked much better. One person said “the environment is so much better”. Another said they enjoyed the interaction with staff.

We noted that the home had a different “feel” to it. We observed people who used the service having “positive interactions with staff. Staff appeared to be much more relaxed and we observed them chatting happily with people. There were activities going on in two of the lounges. People were being supported with drinks and snacks. People looked well cared for and told us the staff were great.

We completed a follow up inspection visit at Alexandra care home to check that the provider had made the required improvements. Although significant improvements had been made, in all the areas that were previously found to be non-compliant, we found that further improvements were required to achieve compliance with all the standards.

We observed that people's dignity and privacy was respected in most cases and people were involved in planning their care, when possible. Although we noted that there had been improvements in the care and welfare of people, we found that further improvements were required as people did not always have their needs met appropriately and in accordance with their care plans. People's safety and well-being was better than it had been on the previous visit, but we observed that people were still at risk because staff did not always have the skills, knowledge and or experience to protect people from risks associated with inadequate care, treatment and support.

We found that many staff were either newly recruited or were from an "agency" and were unfamiliar with the people who lived at Alexandra care home or the processes within the home. This meant that staff were "unfamiliar" with their responsibilities and were reliant on the more experienced staff to direct them.

Quality monitoring arrangements had improved and were much more robust. Likewise, complaints had been recorded and investigated in line with the home’s complaints policy and procedures.

We spoke with people who used the service and their relatives or friends. We were told that there had been improvements in the care that the home provided and that they were happy with the choices that they had. A person who use the service "Felt that they were treated with respect". Another person said that "She enjoyed each day and it was a relief to be living at the home". People and their relatives said they were pleased with the encouragement to contribute to the running of the home by attending regular meetings. We were told by a visitor that " the staff group are busy and committed which helps a lot".

We observed that there were continuing improvements being made to the decoration of the home. We saw that some parts of the home remained under used at present although changes were planned. We saw that new equipment was still being purchased for the benefit of people who use the service. We noted in discussion with the manager and the senior staff that the home is getting better.

When we spoke with a number of people living in Alexandra Care Home on the 13 December 2011 they told us that they felt that their dignity was maintained by care staff and that they were usually treated with respect.They told us that they knew they could make choices about what and where they ate and that they could usually choose what time they went to bed and got up. One person who was in bed told us that this was only because they didn't feel "too good" that morning, but that usually they would get up and dressed for breakfast.

The people we spoke with were overall very positive about the care they were now receiving.' I am beautifully looked after' was what one person told us. Where we received any negative comments these reflected problems associated with the pressure care staff were perceived to be under, which could lead to delays in response to requests for assistance. There was also a very obvious sense in comments made to us that overall their care experience was now improving following a period of significant challenge and change for the home.'Things are getting better' was how one person put this.

In our conversations with people who live in Alexandra Care Home no one raised any concerns about their safety or well-being with us and a number told us that they were very well cared for and that they felt safe in the home.

Although they were in general very positive about the quality of their care experience, they had concerns about the numbers and availability of care staff at times. 'they are very hard working and busy' was one person's comment, linked with the observation that this meant that they sometimes had to wait for help.

People told us that there are occasional meetings where they can discuss the routines of the home with the manager and they felt generally that they were asked about how things are from time to time.

We carried out a responsive review at Alexandra Care Home after we had been informed of some concerns.

Our initial observations were that the home smelt strongly of urine. Almost all the bedroom doors were left open, which meant that people's dignity was compromised. We observed that some people were not appropriately dressed. Most people in one unit had ‘crash mats’ on the floor and had low profile beds. Bathrooms were dirty and out of use and some had no lock on the door.

Staff told us they felt demotivated and undervalued. They said that they were always very busy and that there were frequent changes of staff, which meant there were many new starters leading to inconsistency of the staff on duty. We found that care plans were difficult to follow and the records were inconsistent.

People who used the service told us the staff were very good but they were always very busy. People said that there was not much to do and organised activities were very sparse. People told us they did not like the food and said it was of poor quality.

We shared our concerns with Hertfordshire County Council and they visited the home on the day of our inspection to assess and evaluate some of the concerns we had raised.