This inspection visit took place on 7 November 2018 and was unannounced. It was completed by one inspector, an assistant inspector, a nurse specialist and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

This service was selected to be part of our national review, looking at the quality of oral health care support for people living in care homes. The inspection team included a dental inspector who looked in detail at how well the service supported people with their oral health. This includes support with oral hygiene and access to dentists. We will publish our national report of our findings and recommendations in 2019.

Alexandra is a care home registered to support 39 people. 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. At the time of our inspection 37 people were living at the home.

The accommodation is provided over two floors. The ground floor has a large dining area which has access to the outside space. There is also a large activity living space which also has access to the secure garden. Each floor has bedrooms with ensuite facilities with additional communal bathrooms. The upstairs is divided into to two areas, one has a lounge/dining area. The other has just bedrooms.

Since our last inspection in November 2017, the home has been transferred to a new provider, who retained the registration. This was the new providers first inspection at this location since their registration with us in December 2017.

There was a registered manager at this location. 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. This registered manager has remained constant from the homes previous registrations with other providers.

The governance of the home was insufficient to ensure that people received support to keep them safe and maintain their wellbeing. Audits had been completed, however were not always used to develop the quality and drive improvement. Partnerships had not always been developed to enhance the care available to support people and the staff.

There were not always sufficient staff to support people. The staff had not all received training in the areas they needed to support their role. The provider had not ensured that people were always protected from the risk of infection. Staff did not always feel supported by the registered manager.

Risk assessments had been completed, however for some areas of care the correct guidance had not been followed. Lessons had not always been learnt to drive improvement.

The environment had not been adapted to support those living at the home and the environment was in need of redecoration. We have made a recommendation that the provider looks at current guidance in relation to the environment for people living with dementia.

People were not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. We have made a recommendation that the provider looks at current guidance in relation to supporting people to make decisions.

When people received care, it did not always respect their dignity. People did not always receive the support to make choices and be active in their decisions. These were not supported by documented information. Care plans did not always include people’s preferences, cultural needs and life history.

When people’s needs changed this information was not a

This inspection visit was unannounced and took place on 12 October 2017. Due to concerns raised with regard to the level of staff, we brought our inspection forward and arrived early in the morning to review the staffing levels. We were satisfied with the deployment and number of staff on duty. Since our last inspection the provider has registered under a different registration with the same provider organisation. At our last inspection on May 2016 we rated the service as ‘Good’. At this inspection we found that some improvements were required. The service was registered to provide accommodation for up to 40 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 34 people used the service.

There was a registered manager in post. 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.

People who had behaviours that place themselves or other at risk of harm had not always been managed in a planned way. Some risk assessments had not reflected the support people received. Other risk assessments cover a range of areas and guidance had been provided. People were supported to make choices, however the assessments did not always reflect the person’s level of understanding in different situations. Staffing levels and regularity of the staff had not always provided a consistent approach to meeting people’s needs. This was being addressed by the provider. The staff employed had received a range of checks to ensure they were suitable to work in the home.

People were supported to make choices. We found staff had established positive relationships with people. Staff showed respect for people’s choices and supported them to maintain their privacy and dignity at all times. People were able to choose the meals they wished to eat and alternatives were provided. We saw that medicines were managed safely and administered in line with people’s prescriptions and preferences. Referrals had been made to health care professionals and any guidance provided had been followed.

Staff obtained information from the person and their relatives to support the completion of the care plan. People were encouraged and supported with activities or hobbies they wished to engage in. Complaints had been addressed and resolved in a timely manner.

The registered manager and provider had established a range of audits to monitor improvements within the home. Improvements plans had been developed and actioned. People and relative were consulted about the home and information about any changes was communicated.

Staff felt supported by the registered manager and felt they had the opportunity to contribute to the care people received. Staff had received training and the provider had invested time to expand the staff knowledge in supporting people living with dementia and the development of a senior role within the home.

We saw that the previous rating was displayed in the reception of the home as required. The registered manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check that appropriate action had been taken.