Alexandra Court is a 40 bed intermediate care centre providing a time limited period of assessment and rehabilitation for people being discharged from hospital. People access this service because they are not ready to return home safely or to have physical therapy and rehabilitation.

In response to concerns about a specific incident, we carried out an unannounced comprehensive inspection of Alexandra Court on 8 and 9 January 2018.

The service had received a coroner's Regulation 28: Report to prevent future deaths. A person using the service had slipped from a standing hoist on three occasions, the coroner found this had contributed to the persons death. The coroner also found staff were not adequately trained and had failed to keep proper records of the events. We found the service had responded effectively to this and addressed the concerns raised about training in moving and handling and record keeping. Further improvements had also been made in relation to communication between the health and social care staff.

The service was last inspected in June 2016 when it was rated as good overall with a breach of Regulation 12 of the HSCA 2008, safe management of medicines.

At this inspection we found the service had made improvements in the management of medicines but there remained some risks in relation to the storage of medication for people who were self-medicating. The service addressed this immediately following the inspection and installed lockable cabinets in the bedrooms. We also found there were some anomalies and gaps in the records for medication and topical creams.

This was a continued breach of HSCA (2008) Regulation 12(2)(g) the proper and safe management of medicines. You can see what action we asked the service to take at the end of this report.

The people we spoke with reported feeling safe. There was a safeguarding policy in place and staff were familiar with what might be a safeguarding concern and how to report this. There was a whistleblowing policy displayed in communal areas, the staff we spoke with reported knowing how to raise concerns. People who used the service and visitors also had access to this information.

Risk assessments and plans to manage identified risks were completed for people using the service. We saw that these were reviewed and updated at regular intervals.

Assessments of health and social care needs were completed on admission and we could see that people were closely involved in these. Discharge and goal planning was completed within 48 hours and people using the service told us they had felt supported to get back home and kept informed of progress.

Staff had received appropriate training and records showed that they were up to date with refresher training. Staff were also encouraged to suggest areas of interest for training sessions to develop their knowledge further. Staff reported that they had received good training and felt confident that their practice had improved as a result of this.

The staff were knowledgeable about the Mental Capacity Act 2005 and their obligations under it. Staff were clear about seeking consent from people using the service. The provider was aware of their obligations under the Deprivation of Liberty Safeguards though at the time of inspection there was nobody who was subject to this.

People using the service said that the food was fine and they had plenty to eat and drink. Support was provided for people needing help to manage their food and drink intake. The records were not always completed by the staff. There had not been any harm identified, such as dehydration which indicated that this was a record keeping error.

This was a breach of Reg. 17 good governance, as accurate records had not been maintained for each person. You can see what action we asked the service to take at the end of this report.

The building was clean and well decorated. The furniture was in good condition and there were a few communal areas for pe

Alexandra Court is a 40 bed intermediate care centre that provides a time limited period of assessment and rehabilitation for people who may have had a hospital admission but are not ready to be discharged home safely or to be supported at home. It is a purpose built two storey building with bedrooms on both floors. There is a car park at the front of the home. It is located in Pemberton, near Wigan and is close to shops and public transport links. At the time of the inspection 28 people were using the service.

We carried out this unannounced comprehensive inspection on 12 July 2016. This inspection was undertaken to ensure that improvements that were needed to meet legal requirements had been implemented by the service following our last inspection 09 and 11 September 2015.

At the previous inspection the home was found to have seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, the safe handling of medicines, staff supervisions and staff meetings, staff competency assessments, obtaining people’s consent to care and treatment, safe transfers between different care services, maintaining complete and contemporaneous records and good governance.

At this inspection on 12 July 2016 we found that improvements had been made to meet the relevant requirements previously identified at the inspection on 09 and 11 September 2015. However we found one continuing breach of regulations in relation to the safe handling of medicines, despite finding a significant improvement since the date of the last inspection. You can see what action we told the provider to take at the back of the full version of this report.

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 found the service had an internal safeguarding policy in place. The staff members we spoke with were able to explain the correct procedure for referring safeguarding concerns to the local authority.

The home had a whistleblowing policy in place. We spoke with staff about their understanding of this policy and they told us they were aware of the whistleblowing policy and understood how this worked in practice.

At the previous inspection on 09 and 11 September 2015 we had concerns that personal risk assessments related to people’s safety were not consistently available in all of the care plans we looked at. At this inspection we found the service was now meeting this requirement.

We saw that where accidents and incidents involving people who used the service had occurred, these were recorded and monitored.

At the last inspection on 09 and 11 September 2015 we found that medicines were not handled safely and the provider was instructed to take action to improve the safe administration of medicines. This was a breach of Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment. During this inspection, we found that although improvements had been made in the safe handling of medicines throughout the home, further improvements were still required to meet the requirements of regulations. People who used services and others were not protected against the risks associated with unsafe or unsuitable management of medicines. This was a continuing breach of regulations. You can see what action we told the provider to take at the back of the full version of this report.

Staffing levels were sufficient on the day of the inspection to meet the needs of the people who used the service. We looked at eight staff personnel files and there was evidence of robust recruitment procedures. The files included application forms, proof of identity and references. Disclosure and Barring

We carried out an unannounced focused inspection of this service on 28 January 2015.This inspection was to follow up on whether action had been taken to address previous non-compliance with Regulation 19 HSCA 2008 (Regulated Activities)Regulations 2010 Complaints.

The provider had submitted an action plan to describe what they would do to meet legal requirements. We found that the provider had reviewed their complaints policy and procedure and this was on display. However systems were not in place to ensure an appropriate and timely response to complaints and we saw no audits of compliance to the revised policy. This means legal requirements had not been met.

During this inspection the Inspector gathered evidence to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

During the inspection we looked at care and welfare, cooperating with other providers, supporting workers, quality assurance and complaints.

This is a summary of what we found, using evidence obtained via observations, speaking with staff, speaking with people who used the service and their families and looking at records:

Is the service caring?

During the visit we saw staff offering care with patience and courtesy. Staff made efforts to ensure people’s dignity and privacy were preserved at all times.

The service provided people with information about the service and a questionnaire on admission to ensure their expectations were understood and needs met as far as possible.

We spoke with four people who used the service and six visitors. One person who used the service said, “Staff have been great – can’t do enough for you”. Another told us, “Staff are pleasant and polite. I have been here before but it is better this time”. A third person said, “I like it here, I’ve only been in a short while, but staff are all nice and helpful”.

A visitor remarked, “We have no complaints whatsoever. We are made welcome and staff have made drinks for us”. Another visitor commented, “You are made very welcome, you can make a drink, which we appreciate as we come a long way”.

Is the service responsive?

Assessments were carried out prior to people being admitted, to ensure they were in the correct place to meet their needs. We were told that personal goals were agreed between people who used the service and therapy staff and all staff would then work towards these with the person.

Care plans were contributed to by the person and their family, the care staff and therapy staff. This helped ensure all were aware of the progress being made and plans being followed.

People's support needs and abilities were reassessed on a daily basis and risk assessments were reviewed on an on-going basis to ensure individuals' progress was on track.

Complaints and concerns were generally responded to appropriately. However, we found an example of a complaint that had not been addressed in a timely or appropriate manner and the omission had not been picked up in the audit process. We asked the manager to deal with this as soon as possible.

The service worked closely with other agencies, such as the Stroke Association, Think Ahead, Carer Support and Age UK to ensure people obtained all the assistance and support they needed to help them make a good recovery. Appropriate referrals were made to other services, such as falls service, when required.

Is the service safe?

We saw evidence that care staff were recruited safely and the induction procedure was thorough. Staff told us they were well supported by management.

There were sufficient numbers of staff on duty at the service to ensure people’s needs were met safely. The service was looking at dependency levels of people who used the service, so that people with higher dependency levels could be accommodated on one floor. This would help inform staffing levels and expertise for each level.

Staff training was up to date and on-going and staff with whom we spoke had a good knowledge of care planning, care delivery and risk assessing. Staff with whom we spoke understood how to recognise deteriorating health and well-being and were aware of how to address this.

Areas of high risk, such as falls, were constantly monitored and methods implemented to try to minimise the risk.

Health and safety checks were carried out regularly and the building and equipment were well maintained.

Accidents and incidents were appropriately recorded and audited. Any patterns were analysed and problems addressed in a timely way.

Is the service effective?

The service had a mixture of care and therapy staff in order to try to meet both the social and health needs of people who used the service. There was also a GP who attended the service five days per week to contribute to the multi-disciplinary provision within the home. Staff with whom we spoke demonstrated a good understanding of their roles and responsibilities and all felt they worked well with other disciplines as a team. One staff member told us, “Everyone plays their part, there is good communication, good rapport and team work”

Care plans we looked at included factual and up to date information about people’s health and support needs.

Recent questionnaires filled in by people who used the service indicated a high level of satisfaction. Comments included, “Lovely place, nice people”, “Meals were not terrible, but not wonderful, and, “Staff were brilliant, kind, understanding and patient”.

Is the service well-led?

The home had a manager in place at the home, who was appropriately registered with the Care Quality Commission.

A significant number of audits were undertaken, some internal and some external. The results of these were analysed and any shortfalls addressed to help ensure consistent standards of care within the service.

Questionnaires were completed with people who used the service, to gain their opinions and suggestions and gauge their level of satisfaction. Results were analysed and used to inform continual improvement to the service.

The people using the service who were able to tell us said that they understood why they needed to be at Alexandra Court and that they were happy staying there. Comments included; “lovely here”, “been smashing, staff are belting” and “I am much better, staff are very good”.

We received positive comments about the home from visiting relatives, comments included; “smashing, my relative feels relaxed here”.

We spoke to the GP who was based at the home for five days per week. He explained that he went to see each person when they were admitted and that in his opinion the quality of care was very good.

We asked people about the staff members, comments included, “staff are very kind”, “staff are stupendous, marvellous, respectful and helpful. Nothing is too much trouble” and “staff have been brilliant, nothing is too much trouble, could not ask for more”.

The staff members we spoke to were very positive about the home. Comments included; “I love it here, it is very well run” and “I love my job, good team”.

Alexandra Court had a quality assurance system available to assess the quality of the service it was providing. Questionnaires were given to people when they left the home and the home also produced statistics from daily, weekly and monthly record keeping. All of this information was reviewed quarterly and a summary of all the findings was passed to the Clinical Commissioning Group as part of the intermediate care contract monitoring process.

The people we spoke with who used the service said all the staff were very kind and knocked before they went into their bedrooms. We observed staff supporting and interacting with people who used the service in a respectful, caring manner and good standards of care being provided.

We found that people's needs were assessed and care was planned and delivered in line with their individual care plan. We saw that staff had a positive attitude towards the people who used the service and we observed throughout the visit that staff took time to answer questions and engage with people.

People who used the service said they were happy and felt safe. The people we spoke with knew who to speak to and would not hesitate to raise concerns if they had them.

The training records confirmed that all staff had completed training in safeguarding and were kept up to date in this area. This indicated that they were aware of their roles and responsibilities regarding the protection of vulnerable adults and the need to accurately record and report potential incidents of abuse.

The manager had a training matrix plan to ensure that staff received training that was specific to the needs of the people they were caring for.

We saw evidence that the provider had a system in place for tracking and responding to complaints received. People's complaints were fully investigated and resolved, where possible, to their satisfaction. We also saw evidence of compliments and thank you letters.

Alexandra Court is a 40 bed intermediate care centre that provides a time limited period of assessment and rehabilitation for people who may have had a hospital admission but are not ready to be discharged home safely or to be supported at home. It is a purpose built two storey building with bedrooms on both floors. There is a car park at the front of the home. It is located in Pemberton, near Wigan and is close to shops and public transport links. At the time of the inspection 38 people were using the service.

We carried out this unannounced comprehensive inspection on 09 and 11 September 2015. This inspection was undertaken to ensure that improvements that were required to meet legal requirements had been implemented by the service following our last inspection on 28 January 2015. At the previous inspection on 28 January 2015 the home was found to have one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach related to receiving and acting on complaints. At the comprehensive inspection on 9 and 11 September 2015 we found that improvements had been made to meet the relevant requirements previously identified at the inspection on 28 January 2015.

However at the inspection on 09 and 11 September 2015 we found seven new breaches of regulations in relation to safe care and treatment, the safe handling of medicines, staff supervisions and staff meetings, staff competency assessments, obtaining people’s consent to care and treatment, safe transfers between different care services, maintaining complete and contemporaneous records and good governance.

We found the service did not have appropriate arrangements in place to manage medicines safely in respect of safe storage, the accurate recording of medication administration records, risk assessing people who self-medicate, fridge temperatures and the inappropriate administration of some medicines.

This is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the proper and safe management of medicines because people who used the service and others were not protected against the risks associated with unsafe or unsuitable management of medicines. CQC has issued a Warning Notice with conditions to be met by 17 January 2016.

We saw that some medication audits were being conducted, but it was not clear what actions had resulted and how this information had helped to improve practice. There was no evidence of near miss or error reporting relating to medicines.

This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance; because the service had failed to effectively operate systems and processes to ensure compliance with the requirements in this Part. You can see what action we told the provider to take at the back of the full version of the report.

As an integral part of the purpose and function of Alexander Court, staff members employed by the NHS or social services such as physiotherapists, occupational therapists, social workers and a GP are either based at the home, or work there on a regular basis.

There was a registered manager at the home. 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. On the day of the inspection the registered manager was unavailable due to annual leave and a duty manager, who was a long standing member of staff was in post and providing management cover.

We found the service had a safeguarding policy in place, but not all staff were able to describe the actions they would take in respect of referring a person to the local authority.

This is a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safeguarding service users from abuse and improper treatment. You can see what action we told the provider to take at the back of the full version of the report.

The home had a whistleblowing policy in place which was out of date. Most staff were aware of the policy but did not know how it worked in practice.

The service had a wide range of health and safety policies which helped to assess the risks associated with buildings and premises.

One bathroom which was available to people who used the service was cluttered with equipment.

The service had identified minimum acceptable staffing levels and these were supplemented through partnership working with integrated care teams. On the day of the inspection staffing levels were sufficient to meet the needs of people using the service.

There was evidence of robust recruitment procedures. The staff files included application forms, proof of identity and references. Disclosure and Barring Service (DBS) checks had also been undertaken.

Some staff had received supervision sessions with their line manager, but these were not regular and there was little documentary evidence of these meetings. There was no evidence of regular staff meetings being undertaken and staff competency assessments had not been undertaken.

This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to supporting staff. You can see what action we told the provider to take at the back of the full version of the report.

Staff demonstrated a working knowledge of the Mental Capacity Act (MCA) 2005, the principles of the Act and the decision making process. The majority of staff had undertaken training in safeguarding but not all were able to recall the processes involved.

The environment of the home was clean and free from mal-odours. The decoration was bright and the lounge areas had comfortable seating with the downstairs lounge providing easy access to the garden areas, but the home had few adaptations that would assist a person living with dementia to maintain their independence.

People who used the service and their visiting relatives told us that staff were caring and kind. We found the care and support being provided by staff to be caring and people’s privacy and dignity was respected. We saw that staff ensured they obtained consent prior to delivering care or undertaking a task. We saw staff supporting and interacting with people who used the service in a respectful, caring manner. Staff communication with people was positive and their independence was encouraged.

We found that care management plans had not consistently involved holistic assessments of people’s needs and did not support the provision of effective and appropriate care. Personal risk assessments related to people’s safety were not consistently available in all of the care plans we looked at.

This is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to person-centred care. You can see what action we told the provider to take at the back of the full version of the report.

We saw that some people who used the service had been involved in planning and agreeing their own care with consent clearly obtained, but in some of the care plans we looked at we there was no information to suggest that people who were staying at the establishment, or their families were involved in planning the person’s care.

The service did not routinely provide a range of activities due to it being an Intermediate Care facility with the high turnover of referrals and a short length of stay. People were able to bring personal items into their rooms as required.

People who used the service and their relatives told us that the transition from hospital to Alexandra Court was not always good and frequently disjointed and people often arrived late in the evening when staffing levels were reduced.

We found that one person had been placed at risk by being inappropriately referred to the establishment from the hospital.

This is a breach of Regulation 12(2)(i) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the process of transferring the person from hospital to the home was not done in a way that ensured their safety and welfare.

People we spoke with thought the service was well-led but some people who used the service told us they were dissatisfied with the length of time they had to wait on the hospital ward before transport arrived to take them to Alexandra Court.

Some people told us that they did not feel enough information was shared with them throughout their stay, including information about day-to-day treatment and support, and discharge planning.

We found that some care plans were not fully completed which meant that there was no reliable baseline for care intervention to be planned appropriately regarding people’s rehabilitation needs. Care records were also not always up to date.

This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people care records were not contemporaneous. You can see what action we told the provider to take at the back of the full version of the report.

We saw that comments and suggestions were encouraged through a ‘Quality Assurance and Patient Involvement’ initiative.

The service did not routinely hold residents' meetings because the maximum stay in the home was six weeks and in most cases was less than this. Therefore each person was asked to complete a questionnaire and feedback form when they left the home. This information was reviewed quarterly and a summary of all the findings was discussed at the staff meetings.