The inspection took place on 16 April 2018 and was unannounced. Alexandra House is a care home that provides accommodation with personal care and nursing and is registered to accommodate 38 people. The service supports older people who may have nursing needs or are living with dementia.

Alexandra House 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. At the time of the inspection there were 29 people using the service.

The service had 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.

Alexandra House was last inspected on 25 February 2016 and the service was rated as Good On this inspection the service has been rated as Requires Improvement. Providers should be aiming to achieve and sustain a rating of ‘Good’ or ‘Outstanding’. Good care is the minimum that people receiving services should expect and deserve to receive and we found systems in place to ensure improvements were made and sustained were not effective.

This is the first time the service has been rated Requires Improvement. This was because there was not enough staff to meet people’s needs in a timely manner. This lack of sufficient staffing impacted on all aspects of the service. It meant people had to wait too long for their needs to be met. Staff employed to provide activities had to provide care when staff were very busy. When they rang their call bell, staff checked if they were safe and if they were came back later to attend to them. This could be up to 20 minutes later. People were left unattended at busy times due to pressure on staff.

Risk was recognised and managed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff were aware of the Mental Capacity Act and people’s rights under this.

Staff were aware of their duty of care to keep people safe. They understood what abuse was and how to respond appropriately should they be concerned about people’s safety or welfare.

People’s medicines were administered as prescribed and stored appropriately. Staff were trained to care for the people they supported.

People were not always happy with the food. However people’s dietary needs were recognised and met.

Staff were seen to be kind and caring in their interactions with people. However, some staff did not always acknowledge people when they were in the communal rooms.

Floor covering was worn and broken in some areas, this meant staff could not always clean it effectively. The environment was not well maintained and some areas showed signs of neglect.

People maintained important relationships, as relatives and friends could visit at any time. People were able to regularly review their care to ensure it was still relevant for them. People enjoyed a varied programme of entertainment and support with their hobbies to prevent them from becoming socially isolated, however this could be interrupted due to staff shortages. People knew who to speak with if they wanted to discuss a concern or complaint.

People received support from health care professionals where they needed this to keep well. Staff supported people to attend healthcare appointments and liaised with their GP and other healthcare professionals as required to meet people’s needs. People felt the registered manager was approachable and keen to listen to their views and they were able to share their views about how the service was managed.

We found a breach of the Health and Social Care Act 2008 (Regulated Ac

This inspection took place on 25 February 2016 and was unannounced.

Accommodation for up to 38 people is provided in the home over two floors. The service is designed to meet the needs of older people. There were 27 people using the service at the time of our inspection.

At the previous inspection on 25 and 26 March 2015, we asked the provider to take action to make improvements to the areas of person-centred care, dignity and respect, need for consent, safe care and treatment, premises and equipment and good governance. We received an action plan in which the provider told us the actions they had taken to meet the relevant legal requirements. At this inspection we found that improvements had been made in all areas, however, more work was required in the area of safe care and treatment.

There is a registered manager and she was available during the inspection. 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.

Safe infection control and medicines practices were not followed by one staff member. Incident forms were not always fully completed.

People felt safe in the home and staff knew how to identify potential signs of abuse. Systems were in place for staff to identify and manage risks and respond to accidents and incidents. The premises were managed to keep people safe. Sufficient staff were on duty to meet people’s needs and they were recruited through safe recruitment practices.

Staff received appropriate induction, training, supervision and appraisal. People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate. People’s needs were met by the adaptation, design and decoration of the service.

Staff were caring and treated people with dignity and respect. People and their relatives were involved in decisions about their care. Advocacy information was made available to people.

People received personalised care that was responsive to their needs. Care records contained information to support staff to meet people’s individual needs. A complaints process was in place and staff knew how to respond to complaints.

People and their relatives were involved or had opportunities to be involved in the development of the service. Staff told us they would be confident raising any concerns with the registered manager and that they would take action. There were systems in place to monitor and improve the quality of the service provided, however, statutory notifications had not always been sent to the CQC.

We visited the location to check that the provider had met the warning notice and compliance actions that we set at our previous inspection on 17 October 2013.

We spoke with three people using the service. All of the people we spoke with indicated they felt staff were respectful and treated them with dignity and respect. They were also happy with the care provided by the service.

People told us they received sufficient to eat and drink and that the premises were clean. They told us they would raise any matters of concern or suggestions with the manager and they would be listened to.

We found that people’s dignity was respected and they experienced care, treatment and support that met their needs. We found that people were supported to be able to eat and drink sufficient amounts to meet their needs and effective infection control practices were being followed. We found that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

We visited the location to carry out a scheduled inspection. However, we also carried out the inspection to check compliance in those areas where we set compliance actions at our previous inspection on 10 July 2012.

We spoke with seven people who were using the service. All of the people we spoke with indicated they felt staff were respectful and treated them with dignity and respect. They were also happy with the care provided by the service.

People told us they received enough to eat and drink and that the premises were clean and safe. They were aware of the ways in which they could provide their opinion about the quality of the service, including the complaints procedure. They also did not raise any concerns about the security or content of their personal records.

We found that people’s dignity was still not always respected and they did not always experience care, treatment and support that met their needs. We found that people were not always supported to be able to eat and drink sufficient amounts to meet their needs and effective infection control practices were not always being followed. We also found that the provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

However, we also found that people using the service were protected against the risks of unsafe or unsuitable premises. We found that the provider responded to complaints appropriately and that records were fit for purpose and kept securely.

We spoke with three people using the service. One person told us they had not seen copies of their care plans or records and had not had discussions around their needs. Another person told us they had not discussed their care with staff, had not been asked to complete a survey or attended any meetings to discuss their views of the service. The other person told us they had not seen their care plans, completed a questionnaire or attended any meetings to discuss their views of the service.

People told us they were happy with the care provided and they felt safe living at the service. One person told us their room was quite big and their bed was comfortable. Everything worked and they had enough space. Another person said, “I’ve got a lovely room which is big enough.” Two people told us they would prefer there to be a separate part of the home for people with dementia so they would have more room to walk.

One person said, “They need an extra carer all day, every day. I feel staff are overworked.” However, they told us that the call bell was answered promptly and the other two people who use services told us they did not have concerns about the amount of staff on duty. One person told us there was always someone available if they needed support. The other person told us there was a good response from staff if they needed help. All three people felt staff were good at their jobs. All three people told us who they would talk to if they needed to make a complaint. One person told us they had made a complaint but had not received a response.

We carried out this responsive inspection because we had concerns that this service had not been visited since 2008. During our visit we spoke with a number of residents who told us they were happy with the care and support they received from staff. One resident told us: “The carers treat me in a respectful manner; they do their best for me.” Another resident told us: “The staff give me choices about what clothes I would like to wear each day.”

Residents told us the quality of food was good. One resident told us: “The food is alright.” Another resident told us: “The food is fine.”

Some of the residents we spoke with told us there was a range of activities they could get involved with. One resident we spoke with told us: “They allow you to choose if you want to get involved with activities or not.”

One resident told us they were concerned because of the lack of staff to meet their needs. The resident told us: “We should have had a cup of tea at 11.30am, we did not get this until 12 noon because there was not enough staff. “

All of the residents we spoke with told us that they were well cared for and protected by staff. One resident told us: “I feel safe here.” Residents told us if they had any worries or concerns they would speak to the manager who they believed would deal with the matter quickly and effectively.

The provider had a number of ways in which residents could give feedback about the services they received. We received a mixed response from residents we spoke with. One resident we spoke with told us: “The staff listen to me if I have anything to complain about.” Another resident we spoke with told us: “I have not been invited to any meeting to talk about giving feedback.”

This inspection took place on 25 and 26 March 2015 and was unannounced.

Accommodation for up to 38 people is provided in the home over two floors. The service is designed to meet the needs of older people.

There is a registered manager and she was available during the inspection. 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 and relatives told us they felt safe in the home. Systems were in place for staff to identify and manage risks; however these were not always followed. The premises were not managed to keep people safe. People felt and we found that sufficient staff were on duty. People told us that they received medicines when they needed them and that the home was clean. However, we found that staff did not follow safe medicines management and infection control procedures.

People told us that staff explained what they were going to do but we found that the requirements of the Mental Capacity Act 2005 were not fully adhered to. People told us that staff knew what they were doing but we found that staff were not always fully supported to have the knowledge and skills they needed to meet people’s needs. People liked the food and we found that there was sufficient food and drink available to meet people’s needs. However we found that improvements could be made to people’s lunchtime experiences. People told us that they saw outside professionals but we found that staff did not contact outside professionals promptly when necessary. People told us and we found that the home needed decorating and updating to meet people’s needs.

People and their relatives told us that staff were kind and caring. However, we saw that staff did not always respect people’s dignity and records were not kept securely. We found that relatives were involved in making decisions about their relative’s care; however, people who used the service were not consistently involved.

Staff did not always respond to people promptly. People and staff told us there were not enough activities available and we found that people were not supported to follow their own interests or hobbies. Care records did not always contain sufficient information to provide personalised care. People told us they knew how to make a complaint and we saw that complaints had been handled appropriately by the home.

People and their relatives could raise issues at meetings or by completing questionnaires; however meetings did not take place very frequently. People who used the service, relatives and staff felt the registered manager was approachable. There were systems in place to monitor and improve the quality of the service provided; however, these were not always effective. The provider had not identified the concerns that we found during this inspection.

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.