Alexander Court Nursing Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Governance systems and audits were not effective in identifying or identifying areas for improvement. A quality assurance system was in place, but it needed to become more robust to assess the standards of care in the service. Improvements were needed to the running of the service to ensure people were encouraged to be involved and they received person-centred care. We found two breaches of the legal regulations in relation to safe care and treatment and governance.

This service scored 21 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff and relative’s feedback showed the management team had promoted a listening culture that promoted trust and was focused on learning and improvement. The provider had sufficient oversight to ensure they were alerted to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff.

There was an inclusive culture at the service. Staff and relatives commented on the improvements in the leadership at the service since the new provider took over. However, they also said that these improvements needed to be embedded and sustained to ensure they remained effective.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager had developed a service improvement plan identifying what they needed to do to comply with the relevant standards and to improve the experience of people using the service. They told us that when they took over the management of the service, they had identified gaps and had not felt things were sufficiently robust. They were working towards bridging the gaps and ensuring records were up to date.

There were systems in place to monitor the quality and the safety of the service provided. However, some of these systems needed to be more structured, embedded and sustained to ensure they remained effective. Quality assurance systems were not effective and had not been completed on a regular basis to effectively monitor the quality and safety of the service. Audits that had been completed did not identify theissues we found at this inspection. Some audits, such as care plan audits, had not been completed for a number of months. Improvements were required in maintaining detailed and accurate records relating to the planning and monitoring of people's care. We identified that not all people's care planning documents contained up to date and detailed information and guidance to staff about people's specific care needs, how they were monitored and delivered. The provider and the manager had a good understanding of the duty of candour and a policy and procedure was in place for staff guidance.The management team understood their responsibilities to be honest with people, relatives, and staff when things went wrong

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.