This comprehensive inspection took place on 29 March 2016 and was unannounced. We returned to the home on 21 April 2016 in order to check progress against an action plan that the service sent to us shortly after the date of the inspection. At the time of the inspection, there were 53 people living at the home. Alexandra Grange is registered to provide personal care and support for 54 people. The care home 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 last inspection on 10 January 2014 we found the service to be compliant with all regulations we assessed at that time. At this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of the safe management of medicines, having due regard to people’s well-being when meeting nutritional and hydration needs, and effectively assessing, monitoring and improving the quality of services provided.
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.
People we spoke with who lived at Alexandra Grange and their relatives, told us they felt safe.
We looked at five staff personnel files and there was evidence of robust recruitment procedures in place. Staff were subject to a formal induction process and probationary period.
Staff we spoke with told us they thought access to training and opportunities for on-going development were good.
We looked at staff training, staff supervision and appraisal information. Annual appraisals had either taken place or where scheduled for after the date of the inspection and supervision sessions for care staff were conducted by the manager.
We saw people had risk assessments in their care plans in relation to areas including falls, mobility and moving and handling. Accidents and incidents were recorded correctly.
There was an up to date safeguarding policy in place, which referenced legislation and local protocols. The home had a whistleblowing policy in place, recently reviewed in January 2016.
Staff who administered medicines had all completed appropriate training in the safe handling of medicines. There was a medicines administration policy in use, recently reviewed in January 2016 but this did not refer to the latest guidance from the National Institute for Health and Care Excellence (NICE) regarding the administration of ‘covert’ medicines and guidance on safeguarding in relation to medicines.
The home had a homely remedy procedure within their medication policy. The registered manager informed us that the home did not use homely remedies and where people required medicines for example for pain relief this would be prescribed by the GP.
Fridge temperatures in which medicines were stored were recorded daily, but the fridge which contained medicines was unlocked, which meant that people could potentially access these medicines. ‘Over-stock’ medicines were stored in the clinical room in an unlocked cabinet. This meant that they were potentially accessible by anyone entering the room.
We found that surfaces in the medicines room were unclean with a fine residue of powder which could be seen when wiped and an unclean floor, which was a potential infection control issue.
Not all of the medication administration records (MAR’s) that we reviewed on the day of the inspection had people’s allergy status recorded on. However allergy status was documented on the front cover sheet of each person’s MAR chart. NICE guidance states that allergies should be recorded on MAR charts.
The home was adequately maintained and we saw evidence recorded for the servicing and maintenance of equipment used within the home to ensure it was safe to use. We undertook a tour of the building to ensure that it was safe for the people who lived there and found that it was secure.
We observed several people being transferred with the use of a hoist and sling. The same sling was used for different people which meant there was a potential for the transfer of an infection from one person to another.
We checked whether the service was working within the principles of the MCA and whether any conditions on authorisations to deprive a person of their liberty were being met. We found that the service was complying with the conditions applied to the authorisations. Staff told us they had received training in the MCA and DoLS and most were able to explain the principles of this legislation to us.
Staff were aware of how to seek consent from people before providing care or support and told us they would always asked before providing care.
We looked at the meal time experience for people who used the service on the ground floor unit at Alexandra Grange. One person who used the service was being assisted to eat their main course but they were not given sufficient time to chew their food in-between mouthfuls which resulted in this person experiencing an episode of coughing. After lunch, we looked at this persons care plan and found it clearly indicated that this person must be allowed extra time when eating and drinking.
We also enquired about five other people whose meal had been taken to them in their own rooms. Staff told us that each of these five people required help and support with eating and drinking but their meals had been placed in their rooms by a member of staff, who then left the rooms until such time that the main lunch time service had ended, and a member of staff was then available to go and support these people.
Staff told us that the meal time service was frequently rushed because no additional help was available from the kitchen and because care staff were expected to serve food as well as support people who needed help to eat and drink.
We saw there were some adaptions to the environment, which included pictorial signs on some doors, such as bathrooms, which would assist people living with a dementia to orientate around the home. There were assisted bathrooms with equipment to aid people with mobility problems. New flooring in some of the en-suite bathrooms in people’s rooms had been ordered and was due to be installed shortly after the date of the inspection.
People we spoke with and their relatives told us they felt staff were kind and caring. We observed that interactions between staff and people living at Alexandra Grange were positive and staff were kind and considerate to people.
Staff we spoke with had a good understanding of how to ensure dignity and respect when providing care and support and people we spoke with confirmed that they felt staff respected their privacy and dignity. Residents and relatives meetings were held regularly and people were able to freely contribute to issues about the home.
End of life care training at Alexandra Grange was delivered via a distance learning package for staff and through ‘learning tutor’ visits to the home to support staff undertaking the training. The manager told us that all staff had undertaken EOL training, with the exception of staff who were currently undertaking an NVQ qualification, but staff training records that were provided to us indicated that only 35% of care staff had completed training in end of life care and palliative care. At the time of the inspection no person living at Alexandra Grange was receiving EOL care.
There was a ‘key worker’ system in operation under which each care staff member had specific responsibility for approximately seven people during the day. Alexandra Grange benefited from an activities co-ordinator who worked flexibly at the service over five days. A number of themed days had been undertaken throughout the year to fund raise for a variety of charities and the service also had a year round programme of excursions to various attractions
We looked at the care and support plans of six people who used the service. In each plan we found the quality of documentation and recording was not of a consistently good standard with gaps in information present throughout.
People’s care plans lacked good quality person-centred information. Some of the care plans we looked at were not always dated correctly, some care plans were not signed in every section, some were not dated in every section and others required updating.
The staff we spoke with were all positive about the care home manager. We saw that the registered manager was very visible within the home and actively involved in the provision of care and support to people living at Alexandra Grange.
There was a business continuity management plan in place that identified actions to be taken in the event of an unforeseen event such as the loss of utilities supplies, loss of catering, staff disruption, flood and fire.
We looked at the systems in place to monitor the quality of service provided at the home. There were a range of monthly audits and checks in place.
We saw evidence of recent staff meetings in January and March 2016 and staff supervisions were undertaken regularly.
The views of people who accessed the home for short periods of respite care were also sought and comments from these were largely positive.