About the service:

Alexandra Grange is a residential care home for older people some of whom have some degree of dementia. The home is arranged over three floors with the middle floor dedicated to people who have a diagnosis of dementia. It can provide accommodation and personal care for up to 58 people at any one time. On the day of the inspection 50 people were using the service.

People’s experience of using this service:

¿The registered manager did not always ensure they maintained clear and consistent records when people had injuries and the Duty of Candour was applied. This means providers must act in an open and transparent way with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in relation to care and treatment.

¿We made a recommendation to explore relevant guidance on how to ensure environments used by people with dementia were more dementia friendly.

¿We have made a recommendation about seeking guidance from a reputable source to ensure principles of the Accessible Information Standard are met.

¿There was an activities programme and some people were involved in activities. The registered manager took action to ensure all people had opportunities for social engagement and meaningful activities according to their interests to avoid isolation.

¿People felt safe living at the service. Relatives felt their family members were kept safe.

¿Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately.

¿Recruitment processes were in place to make sure, as far as possible, that people were protected from staff being employed who were not suitable.

¿People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

¿We observed kind and friendly interactions between staff and people. People and relatives made positive comments about the staff and the care they provided.

¿People told us staff were available when they needed them and staff knew how they liked things done most of the time. The registered manager reviewed and improved staffing numbers to ensure enough qualified and knowledgeable staff were available to meet people's needs at all times.

¿Staff training records indicated which training was considered mandatory by the provider. The registered manager had planned and booked training to ensure staff had appropriate knowledge to support people. Staff said they felt supported to do their job and could ask for help when needed.

¿There were contingency plans in place to respond to emergencies. The premises and equipment were cleaned and well maintained. The dedicated staff team followed procedures and practice to control the spread of infection and keep the service clean.

¿People had sufficient to eat and drink to meet their nutrition and hydration needs. Hot and cold drinks and snacks were available between meals.

¿People had their healthcare needs identified and were able to access healthcare professionals such as their GP. The service worked well with other health and social care professionals to provide effective care for people.

¿People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately.

¿People confirmed staff respected their privacy and dignity. The registered manager was working with the staff team to ensure caring and kind support was consistent.

¿We observed people were treated with care and kindness. People and their families were involved in the planning of their care.

¿The service carried out risk assessments and had drawn up care plans to ensure people's safety and wellbeing. Staff recognised and responded to changes in risks to people who use the service and ensured a timely response and appropriate action was taken.

¿The registered manager held residents and re

This inspection took place on 2 and 4 August 2016 and was unannounced. Alexandra Grange is a residential care home for older people some of whom have some degree of dementia. The home is arranged over three floors with the middle floor dedicated to people who have a diagnosis of dementia. It can provide accommodation and personal care for up to fifty eight people at any one time. On the day of the inspection forty four people were using the service.

At the time of the inspection 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.

The provider completed thorough recruitment checks on potential members of staff. Maintenance and checks of the property and equipment were carried out promptly and within required timescales. Checks on fire alarms and emergency lighting had been completed in accordance with the provider’s policy and manufacturer’s instructions.

There was a system to ensure people received their medicines safely and appropriately. The quality of the service was monitored by the registered manager and the provider through gaining regular feedback from people and their representatives and auditing of the service. The provider had plans in place to deal with emergencies that may arise.

People who use the service were able to give their views about the quality of the care provided. Relatives, community professionals and commissioners told us they were very happy with the service they received from Alexandra Grange and felt that people were safe using the service. The service had systems in place to manage risks to both people and staff. Staff had good awareness of how to keep people safe by reporting concerns promptly through procedures they understood well. Information and guidance was available for them to use if they had any concerns.

People were treated with kindness, dignity and respect. They were involved in decisions about their care as far as they were able and relatives/representatives told us they had been asked for their views on the service for particular individuals. People’s care and support needs were reviewed regularly. The registered manager ensured that up to date information was communicated promptly to staff through regular meetings.

Staff felt very well supported by the registered manager and care manager (deputy manager) and said they were listened to if they raised concerns and action was taken without delay. We found an open culture in the service and staff were comfortable to approach the registered manager or any member of the management team for advice and guidance.

Staff understood their responsibilities in relation to gaining consent before providing support and care. People’s right to make decisions was protected. New staff received an induction and training in core topics.

We carried out an unannounced comprehensive inspection of this service on 13 and 14 January 2015. Breaches of three legal requirements were found. We issued warning notices for breaches in relation to the provider maintaining accurate and secure records, and ensuring consent to care was sought in accordance with the principles of the Mental Capacity Act (MCA) 2005. We issued a compliance action for a breach relating to safe administration and disposal of medicines.

The provider was required to meet the regulations relating to the warning notices by 6 April 2015. They told us they would address the breach relating to medicines by 31 March 2015.

This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Alexandra Grange’ on our website at ‘www.cqc.org.uk’.

Alexandra Grange provides residential care for up to 58 older people without nursing needs, but with other care needs, including dementia care. At the time of our inspection 40 people were living in the home.

Since our inspection in January 2015, a new manager had submitted their application as the home’s registered manager. They had been in place as the manager of this home for ten days at the time of our inspection. They were being supported through their induction by the provider’s managerial and regional staff, including the person who was managing this home at our inspection in January 2015. 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 and associated Regulations about how the service is run.

At our focused inspection on 28 May 2015, we found that the provider had taken action to ensure the requirements of the Regulations had been met.

People’s medicines were stored, administered and disposed of safely. The provider had put systems and checks in place to ensure issues, omissions and errors were identified promptly, and actions demonstrated that learning occurred to address these issues and reduce the risk of repetition.

People’s consent to care was documented. When people declined specific areas of care, this was recorded, and their decisions were supported. Where people were unable to sign their consent, records documented how the person had indicated their wishes. If staff were unsure of a person’s capacity to consent, an assessment of their mental capacity was documented, and a decision was made and recorded on their behalf by those appropriate and with the person’s best interests at heart, such as family, staff or health professionals. Relatives had been supported by the provider to understand the principles of the MCA 2005, including the role and limitations of power of attorney.

Where people had been identified at risk of harm from malnutrition, dehydration or pressure sores, staff completed charts in full to record the support provided to people over each 24 hour period. This ensured people received the care and support they required to protect them from identified risks.

Records were stored in staff offices that were kept locked when unattended. Staff understood and implemented the provider’s policy regarding records security. Managers conducted daily checks to ensure confidential information was maintained securely.

The provider had taken sufficient action to meet the requirements of the warning notices and compliance action in relation to maintaining accurate and secure records, ensuring lawful consent to care was obtained and documented, and the safe administration and disposal of medicines.

This inspection was carried out to look at new concerns raised with CQC since our last inspection on 28 August 2012. Those concerns related to how the provider was making sure there were enough staff to meet people’s needs in the home. Another concern related to how the provider was ensuring people living in the home were being cared for in a clean, hygienic environment.

During our inspection we observed a clean environment throughout the home. People living in the home and relatives we spoke with told us the home was always kept clean and tidy. People were protected from the risk of infection because protocols based on current Department of Health guidelines had been followed. We found there were systems in place to manage and monitor the prevention and control of infection.

The home appointed a new manager in January 2013 and restructuring of the staff team was taking place. We spoke with staff, looked at staff training records and shift patterns worked by staff. We found the majority of staff had attended training and future dates were booked for those that had not. All staff had received an induction prior to commencing their role independently.The staff rota showed there were enough staff to meet people’s needs and identified additional domestic staff employed to promote a clean and hygienic environment. People living in the home told us they were happy with the staff team and services provided. One person said “staff are very good. All my needs are being met.”

At the time of our inspection only 37 people lived at the home. We spoke with 10 people who used the service, two relatives and six members of staff. We also received feedback from one social care professional about the quality of services provided by the home.

The people who lived at the home were highly complimentary about the quality of accommodation, the choice of food and the attitude of the staff team. They told us the staff were "lovely, couldn't be better", "they always help me when I need them" and "I've absolutely no complaints, the staff are kind and friendly", "it's just like home". Relatives said "staff are genuinely caring" and "staff are lovely, very caring and kind". However, relatives did also comment "the staff do seem a little pushed at times and maybe a little overworked" and "the staff are always busy".

People were generally positive about the staff and the care they received, but felt they had to ask for things and sometimes staff were too busy. A visiting health care professional told us that their advice was not always followed appropriately, but this was improving.

Some people and visitors told us that there were not enough staff to meet the changing needs of people.

One person told us they were now able to manage their own medicines, which was an improvement, but we found that people had not always had their medicines managed appropriately.

Recently there had been changes to the management of the home and people did not feel that they had been kept fully informed about them.

All the people that we spoke with said that they were satisfied with the care and support that they received and felt that they were well looked after.

People who lived at Alexandra Grange said that they were generally satisfied with the service that they received. They said that staff treated them well. We saw examples of where people’s privacy and dignity had been respected. For example, one person had requested that they should not be disturbed at night by staff and this had been observed. Another person, however, said that they sometimes had to wait a long time for assistance when they wished to go to the toilet

Two people commented on the change in the service recently. One person said “Since last week I cannot fault it”. Another said that they had, in the last few days, been asked a lot of questions about their care needs. People and their relatives that we spoke to said that they had not seen their plan of care.

One visitor told us that they had been told that their husband could not keep his GP when he moved to Alexandra Grange, despite the GP practice being quite local. We spoke to the manager about this at the time of our visit.

One person who needed to use a hoist to move safely said that they felt safe whilst staff were hoisting them but said that they found it uncomfortable. They said that they wanted to become more mobile again and we saw an appointment that had been arranged for them to consult with a physiotherapist.

One resident said that she looked around before the home opened and said that her needs had been assessed. A relative said that she believed her husband’s needs had been assessed before he moved in but said that she had not been involved in the process

The inspection took place on 13 and 14 January 2015 and was unannounced.

Alexandra Grange provides residential care for up to 58 older people including people living with dementia. At the time of our inspection 39 people were living in the home.

The home consisted of three floors. There were individual en-suite bedrooms and shared bath or wet rooms on all floors. The Peacock top floor cared for people with residential needs. The Monarch first floor catered for people living with dementia. The Grayling ground floor accommodated people with personal care needs and people living with the earlier stages of dementia. Communal lounges and dining rooms were available for people on all floors. Stairs and a lift provided access between floors. A range of communal areas, including a hairdressing salon, and a café open 24 hours daily, were available for people’s use. The doors to Monarch were secured with a keypad, to ensure people were protected from dangers that could affect their safety. People able to independently leave the home or floor safely knew the codes to do so, otherwise they were supported to leave as they wished.

A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (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. The provider confirmed that a person had been appointed to this role shortly after our inspection, and would be applying with CQC to take up the post of registered manager.

During this inspection we checked whether the provider had taken action to address the nine regulatory breaches we found during our inspections in May 2014 and July 2014. The provider told us that they would have completed their action plan by end of November 2014.

We found the provider was working towards improving the service. The provider had implemented a system of quality and risk checks to support the manager to monitor the service and drive improvement. It was too early to assess the effectiveness of these systems in promoting sustained improvement in the quality of the service people received. Though improvements had been made, we found ongoing concerns relating to the practices of record keeping, medicine management and gaining people’s consent.

People’s care records were not always kept securely. Daily care records did not reflect the care delivered to people to ensure they stayed healthy and safe. These incomplete records did not enable the manager to tell whether people’s care had been delivered effectively.

Though our previous concerns about medicine management had been addressed we found new evidence of unsafe medicine administration and disposal. The provider had identified similar concerns and was working with the community pharmacist to improve practice.

Where people lacked capacity to make decisions about their care, decisions had not been made lawfully in line with the principles of the Mental Capacity Act 2005 (MCA). The provider had not taken sufficient actions to protect people’s rights.

The provider had improved their learning from safety incidents. When safety incidents occurred these had been investigated, analysed and preventative action taken to keep people safe.

The provider employed sufficient staff and the recruitment process was robust to ensure people were supported by appropriate staff. Staff support and supervisions had improved. This was confirmed by the staff we spoke with. Where staff performance had fallen below an appropriate standard the provider had taken action to address shortfalls.

People were cared for by staff who were kind and respectful of their needs and wishes. Their dignity was promoted by thoughtful consideration. People were involved in decision-making in the home, both with their own care planning and in areas such as staff recruitment. The complaints process ensured people’s concerns were addressed appropriately.

People, relatives and staff acknowledged progress towards a stable management team in the home, and spoke with confidence about the manager in post at the time of our inspection.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.