This inspection took place on 13 June 2017 and was unannounced. Alexandra House is a 22 bed residential home for older people who are physically frail and require help with personal care; it does not provide nursing care. When we visited, 20 people lived there. A small number of whom were living with dementia. At our last inspection in May 2015, the service was rated good. At this inspection we found the service remained good in most key questions. Further improvements had been made which reflected that the Caring key question was outstanding. Therefore, the overall rating remains good.

Staff developed exceptionally positive caring and compassionate relationships with people. The ethos of the home was that of an extended family. Staff knew each person as an individual and what mattered to them. They treated people with the utmost dignity and respect during their life and at the end of their life. The whole staff team were extremely passionate about providing people with support based on their individual needs and aspirations.

People received care based on best practice, by staff with an in-depth knowledge of their care and treatment needs. Staff were skilled and confident in their practice. Staff worked with people, other professionals and continually developed their skills. The service trained and developed staff to put their learning into practice to provide care that met people's individual needs.

People's experience of eating and drinking was enhanced because staff promoted improved health and wellbeing through good nutrition and hydration.

Each person had a trusted member of staff, known as a keyworker, who took a lead role in each person's care and wellbeing. They continuously looked for ways to ensure people had positive experiences and led fulfilling lives. Staff knew about people's lives, their interests and talents and encouraged them to share them with others.

There were enough staff on shift to meet the needs of people who used the service. People were supported to have as much choice and control over their lives and were supported in the least restrictive way possible. Policies and systems in the service supported this practice.

Staff understood how to keep people safe and could describe the correct steps they would take if they were concerned that abuse had taken place. Accidents and incidents were appropriately recorded and investigated. Risk assessments were in place for people who used the service.

Medicines were managed safely and staff members understood their responsibilities.

There was a strong culture within the service of treating people with dignity and respect. People and the staff knew each other well and these relationships were valued. The staff, registered manager, and management team were always visible and listened to people and their relatives and friends, offered them choice and made them feel that they mattered.

There was a culture of openness and transparency at the service. Staff were extremely positive about the management and leadership which inspired them to deliver a high quality service. They encouraged ideas from staff to benefit the people in their care and maintain a strong, stable staff team with a shared goal.

The management team undertook regular audits and improvements were carried out when these were needed. The quality of the service was monitored and assessed consistently. The registered manager gathered people's views and used this information to look at ways they could continuously improve the service.

People who used the service, family members, and visitors were encouraged to make comments, complaints, or compliments about the service.

Further information is in the detailed findings below.

The service provides accommodation and personal care for up to 22 older people. 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 and associated Regulations about how the service is run.

We saw people were well cared for, relaxed and comfortable in the home. Everyone we spoke with complimented and praised the staff who supported them.

Care records were personalised and reflected people’s care and support needs. The care plans included information about peoples’ likes, interests and background and provided staff with sufficient information to enable them to provide care effectively. We observed people were cared for with dignity. People told us they were respected by staff.  

People were cared for by an established, motivated, passionate and well trained staff team. The registered manager and her senior team provided effective leadership to the service and regular residents meetings ensured people were involved in the running of the home. The atmosphere in the home was sincere, sociable and understanding and we saw staff were able to spend time chatting and laughing with people.

People were actively involved with the local community as they wished. Staff supported and encouraged people to engage with a wide variety of activities and entertainments available within the home. They also respected people’s wishes to be by themselves. Professionals who worked regularly with the service told us that it was well run and they had no concerns about people’s care.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask. This is what we found:

Is the service safe?

People felt safe because their rights and dignity were respected when making decisions about any risks that they may wish to take. The registered manager described a situation when a person displayed behaviour that challenged staff and other people who used the service. The staff team dealt with this situation well in collaboration with other health professionals to keep people safe.

People were safe because the service had good system to manage accidents and falls and learnt from them, so they were less likely to happen again. For example, the service had a falls prevention officer, whose role it was to analyse and monitor falls and assist people to maintain their safety after a fall.

Staff understood about the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and how they would be put this into practice. No DoLs applications had been submitted.

The people considered they were kept safe and were listened to. We observed that people were free to go about their daily routine as they wished. One person told us, “I feel happy here. The staff are always on hand to help me and I can do as I please”. Another person said, “Since my fall the staff have helped me enormously. I have a special routine and my call bell is always placed near me wherever I choose to sit”.

Is the service caring?

The people we spoke with told us they felt that their dignity was respected and they were assisted to live their life as they wished. Staff took the time to find out people’s personal social histories. Staff we spoke with knew people’s needs well and how they wished to be cared for. This meant that staff cared about the person as an individual and were concerned about their well-being.

People and those that mattered to them were encouraged to make their views known about their care. We saw that weekly emails were sent to family members asking for an update on their point of view regarding the care of their relative. A relative we spoke with confirmed that this was a positive gesture and they considered their views were professionally respected. This meant that people were listened to and they felt that their views mattered.

Is the service responsive?

The registered manager and the team of staff demonstrated a clear understanding of the importance of communicating with people and their relatives to find out their aspirations, preferences and diverse needs. For example, the team were undertaking an in depth review of how to provide support and care at the end of a person’s life. This was done in full consultation with people who used the service and their family or advocate.

Is the service effective?

Staff had identified the need to review the content and arrangements of care plans so that they were more clear and accessible to people and staff. This would improve the standard of recording and make care provision more effective.

People were involved in the assessment of their needs and one person said, “The manager asked me a lot of questions and after I had been in a while they asked me if my views were the same or had changed. I found this reassuring because you don’t always know what you feel when you’re in the middle of changing your whole life”.

People told us they were happy to discuss their personal preferences with staff. They said that staff kept an eye on them and got help very quickly if they were unwell. We saw how the service had referred an individual to health professionals when their mental health had deteriorated. This meant people were supported to maintain good health, have access to health care services and received ongoing support.

Is the service well led?

The management and staff demonstrated values that included involvement, compassion, dignity, respect and independence. Staff we spoke with showed they understood this as they discussed their role and responsibilities in their work. This meant the service promoted an open culture that was centred on the individual and empowered them to take control of their life as they were able.

Developments in guidance and best healthcare best practice were used as an opportunity for learning and improvement. For example, the service was exploring how they could provide end of life care better so that people were empowered to make advanced decisions or be assured of appropriate management and decision making on their behalf.

Concerns were listened to. The service hadn’t received any complaints but people told us they would “Go straight to the manager” if they were unhappy.

The management had systems in place to assess and monitor that staff had the right competencies, knowledge, qualifications, skills and experience to meet the needs of people at all times, no matter how complex their needs became. Resources and support were available to staff to develop and drive improvements in care, for example, manual handling and falls prevention. This meant staff were motivated to carry out their role and to meet people’s needs.

People shared their experiences of the care and support they received. Comments included, "I have no complaints, and I am very well looked after here. The staff are very helpful", and "We have activities to do and we are supported to participate in them. There is a very good atmosphere here and the staff are kind".

People said they felt safe living at the home. One person commented, "The staff treat me well and are very caring. I can see the doctor when I need to and they all keep an eye on my health".

Staff told us they had attended a range of training courses to equip them with the knowledge and skills to effectively carry out their duties.

There was evidence that residents' views and the opinion of their relatives were being sought and listened to.

The provider monitored the service robustly. The systems in place enabled them to identify problems swiftly and act upon them to be responsive to people’s needs. The management arrangements in place were effective which meant that the service was well led.

We carried out this inspection to check on the care and welfare of people who used this service.

We spoke to seven people who used the service and five staff during a visit to the service on 17 July 2012.

There were many positive comments and overall people were pleased with the care and support they received. Many comments were made about staff being kind and caring, helpful and friendly.

People who used the service said they had received information before they agreed to the service. They had been able to visit the home and look around. They said they had talked to the manager about their needs and were told whether they could be met at the home. People commented that they were asked about how they liked tasks to be done.

People who used the service said they felt able to raise any issues they had with the staff. People told us that they felt safe. One person said, “Staff are good at listening and do their job well. We can be confident they can care for us as we prefer and try to help us remain independent”.

People said they were treated as individuals and any change to their care was communicated to the care workers speedily which ensured consistent quality care. People said the staff often asked them their views about the service and were keen to rectify any problems.