This inspection took place on 6 September 2018. We previously inspected the service on 25 and 31 May 2017 and it was rated ‘Requires Improvement’ overall. We found significant improvements had been made and the rating at this inspection is Good.

Alexandra House 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. Alexandra House accommodates nine people in one adapted building. There were nine people living at Alexandra House on the day of our inspection.

The care service has been developed and designed in line with the values that underpin the ‘Registering the right support’ and other best practice guidance. These values include, choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

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 and associated Regulations about how the service is run.

The service had suitable systems for identifying and responding to allegations of abuse. Recruitment processes ensured that new staff were of good character and suitable to work with people.

Staff had received training appropriate to their role. Staff had received training around safeguarding and were confident to raise any concerns relating to potential abuse or neglect. Staff received regular supervision from the management team.

The administration and management of medicines was safe. There were sufficient numbers of staff working at Alexandra House.

Risk assessments were updated to ensure people were supported in a safe manner and risks were minimised. Where people had suffered an accident, action had been taken to ensure the ongoing safety of the person.

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. People were encouraged to make choices about their day to day lives. People were supported to access health professionals. They could choose what they liked to eat and drink and were supported on a regular basis to participate in meaningful activities. People were supported in an individualised way that encouraged them to be as independent as possible.

The service worked in line with the principles of the Mental Capacity Act 2005 in terms of people’s consent to care and acting in their best interests where appropriate.

People and their relatives were positive about the care and support they received. They told us staff were caring and kind and they felt safe living in the home. We observed staff supporting people in a caring and patient way. Staff knew people they supported well and were able to describe what they liked to do and how they liked to be supported.

The service was responsive to people’s needs. Care plans were person centred to guide staff to provide consistent, high quality care and support. Daily records were detailed and provided evidence of person centred care.

The service was well led. Quality assurance checks were in place and identified actions to improve the service. Staff and relatives spoke positively about the management team. People’s feedback and the views of relatives and staff were sought to make improvements to their experience of the service.

We inspected Alexandra House - Gloucester on the 25 and 31 May 2017. Alexandra House – Gloucester provides accommodation and personal care to people living with learning disabilities and physical disabilities. The home offers a service for up to 10 people. At the time of our visit seven people were using the service. This was an unannounced 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.

We last inspected the home in May 2016 and found the provider was not always meeting the regulations. We found the service did not have effective systems to monitor the quality of the service. Where concerns had been identified, appropriate action was not always taken. The service did not maintain an accurate, complete and contemporaneous record in respect of each person using the service. Following our inspection in May 2016, the registered manager issued us with a plan of the actions they would take to meet these breaches in regulation. At this inspection we found appropriate action had been taken, however there was still scope for improvement in the monitoring of some people’s care needs.

People’s care plans were current and reflected their needs. However, where people’s healthcare needs were being monitored there was not always clear guidance for staff to follow on how much support people needed and when to raise concerns.

The registered manager had effective systems to monitor the quality of service people received. However there were limited systems carried out by the provider to ensure people were receiving quality care. Care staff felt supported by the registered manager however they did not feel supported by the provider.

Healthcare professionals spoke positively about the registered manager and care staff and how they met people’s needs. People were supported with their nutritional needs. Staff sought and acted upon the advice given to them by healthcare professionals. Staff had access to the training and support they needed to meet people's day

People enjoyed busy and active lives at Alexandra House. People were supported to access the community, and their independence and personal relationships were promoted. People were comfortable with care staff at Alexandra House - Gloucester.

Staff were supported by a committed registered manager. There were enough staff with appropriate skills deployed to meet the needs of people living at the service and support them with activities. Staff spoke positively about the home and the registered manager.

This inspection took place on 28 April and 3 May 2016 and was unannounced. Alexandra House - Gloucester provides care and support for up to 10 people who have a learning disability or physical disability. The service is located near the centre of Gloucester close to a range of local amenities. At the time of our inspection there were eight people were using this service.

We last inspected the service on the 2 May 2014. At this inspection we found the provider was meeting all of the requirements we inspected.

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 and associated Regulations about how the service is run.

There were systems in place to enable the provider to gather feedback from people or their relatives. However not all feedback was used to help drive improvements. The registered manager and provider had systems to identify concerns about the quality of the service. However where actions had been identified, the provider action had not been taken action to approve and rectify these concerns. People’s care records were not always completed consistently and were not always personalised to people’s needs.

People were safe within the home. Care staff had a good understanding of safeguarding and the service took appropriate action to deal with any concerns or allegations of abuse. Staff managed the risks of people’s care and understood their responsibilities to protect people from harm. People received their medicines as prescribed.

People had access to plenty of food and drink and received a diet which met their needs. Staff ensured people’s on-going healthcare needs were met. There was a friendly, pleasant and lively atmosphere within the home. People were supported to go out in the local community and on day trips. People enjoyed the time they spent with each other and staff. Staff ensured people were offered choices about their day. Where people did not have the capacity to make specific decisions, the registered manager ensured they had an independent advocate and a best interest assessment was carried out.

People were supported and cared for by kind, caring and compassionate care staff. Care staff knew the people they cared for and what was important to them. People were supported by care staff who were knowledgeable and had access to the training they needed to meet people’s needs. Care staff felt supported by the registered manager. There were enough staff to meet the needs of people living at the home.

The registered manager had a clear vision for the service, which was shared by all care staff. The registered manager had systems to identify shortfalls within the service and where able make necessary improvements. The registered manager ensured people and their relatives views were sought and acted upon.

We found a breach 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.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual's name from our register.

We were unable to ask people about their views of living in the home because of their complex communication needs. However, we observed that staff understood the best way to communicate with people and were able to support people to make choices about their daily living. Staff interacted with people respectfully, with good humour and in a manner appropriate to each individual’s needs. Care plans were personalised to each individual's needs and from the people we observed we saw that they accurately reflected their needs and wishes.

Appropriate arrangements were in place in relation to the recording of medicine. There were enough qualified, skilled and experienced staff to meet people’s needs. People’s personal records were accurate and fit for purpose.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual's name from our register.

We were unable to ask people about their views of living in the home because of their complex communication needs. However, we observed that staff understood people’s needs and were able to offer them choice and support them to do what they wanted in the home and take them out. Staff interactions were respectful and at the pace of the person they were working with.

Care plans were personalised to each individual's needs and detailed the wishes of the person and how they wanted to receive their support. Care was provided in an environment that was safe, well maintained and met people’s needs. We found some shortfalls in record keeping in relation to care plans, nutrition intake and activities.

We saw notes of monthly key worker meetings and these showed that people were asked about their views of living in the home. We also saw that where people expressed a view about their daily living or about activities they would like to take part in these were acted upon.

People living at Alexandra House had a high level of needs and not everybody at the home could express their views verbally. They received support with making decisions and there was a choice of communal areas within the home. These included a sensory room, activities room and a television lounge.

Staff had got to know people's preferred communication methods and how each person showed their feelings. Information was presented in different formats so it was easier for people to understand. Photographs, for example, were being used to help people choose activities and the places they would like to visit.

Staff had guidance for supporting people safely and in a way which met their individual needs. Staff were kept busy during our visit and the staffing levels were described in terms such as “adequate” and “manageable”.

A single inspector carried out this inspection over two days. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

In this report the name of a registered manager appears who was not in post and not managing the regulated activities at this location at the time of this inspection. Their name appears because they were still Registered Manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual’s name from our register.

Is the service safe?

People were not able to tell us if they felt safe due to their complex communication needs. Relatives we spoke with did not have concerns about the safety of people living in the home. People had care plans that contained information to help staff provide safe and effective care. These were supported by risk assessments.

The provider responded appropriately to allegations of abuse. Staff we spoke with knew what actions to take if they had a concern and we saw evidence of up to date training having been provided. The Deprivation of Liberty Safeguards (DoLS) were only used when it was considered to be in the person’s best interests. No one was subject to a DoLS authorisation at the time of our inspection. Where there were restrictions in place these were justified in people’s care plans.

Regular checks on the environment were carried out to ensure any defects were identified and action taken to rectify them. Gas, electrical, fire and water safety checks were completed as were appropriate lift inspections.

Is the service effective?

Staff received appropriate professional development. The registered manager told us training needs were monitored by the company’s human resources department. We reviewed the summary of staff training and found most staff had completed all training identified as mandatory by the company. This meant people were supported by staff who had received the necessary training. Staff we spoke with were positive about the training they had received.

The results of the 2013 satisfaction survey showed relatives were generally happy with the support provided. We spoke with the relatives of two people. They were both positive about the care provided and made comments such as “Very happy” and “Brilliant”.

People were receiving enough food and drink to keep them well and eating guidelines from professionals were being followed. Some staff questioned the quality of the food being provided, particularly in the evening. The registered manager told us they would review the quality and variety of the meals provided, particularly those in the evening, following our inspection.

Is the service caring?

People’s care plans were person centred and focused on people’s needs and preferences. We spoke with the relatives of two people. They were both positive about the care provided and made comments such as “Very happy”, “People I deal with have the utmost respect for [name]” and “Staff I have contact with know [name]’s preferences and little ways”.

Whilst we saw some staff communicating well with people and involving them in decisions, other staff did not always take the time to engage with people. For example, one person was moved using a lifting belt but they were not informed beforehand and during the procedure what was happening. There was no effort made to gain their consent before beginning the procedure.

Although people’s basic care needs were being met both staff and professionals from outside the home acknowledged that people were not being interacted with and engaged in activities as much as possible. Staff told us this was due to a lack of time.

Is the service responsive?

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. People’s relatives or advocates had been asked to complete questionnaires about the quality of the service as people were not able to do this themselves due to their complex communication needs.

The registered manager told they had not received any complaints during 2013-14. Information about making a complaint was available in an easy to read format. Staff also explained to people how to make a complaint at key worker meetings. Key worker meetings were an opportunity to monitor how happy people were with the support they were receiving.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented. Incident reports were produced by staff which included a section on lessons learnt, the agencies to be informed and the actions to be taken. We saw evidence that the identified actions had been taken. This ensured that similar incidents were less likely to occur.

Is the service well led?

Staff told us they felt well supported by the registered manager. They felt staff turnover had reduced as a result and they felt the team was becoming more stable. Staff were receiving supervision and appraisals to help them reflect on their roles and responsibilities. One member of staff told us observations of care did not take place. They suggested this would help the registered manager identify training needs for staff.

The registered manager told us quality audits were completed, for example regarding care plans, safeguarding and care provided at night. Quality reviews had also been carried out by other organisations. A staff satisfaction survey was completed in 2013. Staff identified they were encouraged to put forward ideas for improvement but fewer staff felt their ideas were appropriately considered. Seventy per cent of the staff that responded felt they were encouraged to check the quality of their work.