The inspection was unannounced and took place on 18 October 2018.

Alexandra House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation with personal care for a maximum of 36 people. There were 28 older people living at the home on the day of the inspection, some of whom were living with dementia.

This is the third time the service has been rated Requires Improvement. For services rated Requires Improvement on one or more occasions, we will take proportionate action to help encourage prompt improvement. The service was rated requires improvement because the provider needed to embed their governance systems and improve the medication system, staffing numbers and record keeping. Two breaches of regulations were identified and we have also made a recommendation about the management of some medicines.

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.

The provider had a programme of audits in place to monitor the quality and safety of people’s care and support, however up until recently these had not been carried out effectively. The provider continually strived to make things work better so that people benefitted from a home that met their needs. However, further improvements are needed to demonstrate the provider’s overall governance is implemented and sustained over time.

People told us staff were not always available at the times they needed them, including during the night. Staff turnover was high and this impacted on continuity of care and the overall cleanliness of the home environment. Care staff did not have time to spend time socially with people or offer and encourage activities.

People told us they received their medicines from staff who managed their medicines in the right way. People also felt that if they needed extra pain relief or other medicines as needed these were provided. People who administered their own medication needed to better supported to ensure that both the person and staff had risk assessments and procedures in place. Staff wore protective gloves and aprons to reduce the risks of spreading infection within in the home.

Overall, people told us they felt safe living at the home and that staff supported them with maintaining their safety. Staff told us about how they minimised the risk to people’s safety and that they would report any concerns to the management team.

People were involved in planning their care, which included end of life planning where required. Staff had a good understanding of people’s care needs, however, people’s care plans and risk assessments did not always contain up to date information which reflected their current needs.

Staff had undertaken training and their knowledge reflected the needs of people who lived at the home. People told us staff acted on their wishes and their agreement had been sought before staff provided support.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the provider’s policies and systems supported this practice. People who lack mental capacity to consent to arrangements for necessary care or treatment can only be deprived of their liberty when this is in their best interests and legally authorised under the MCA. The procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS).

People told us they enjoyed their meals, had a choice of food and were supported to eat

We carried out this inspection on 9 August 2017 and it was unannounced.

Alexandra House provides care for up to 36 older people in Solihull. At the time of our inspection there were 27 people living at the home. Some people lived with dementia.

We last inspected this service October 2016 and gave an overall rating of ‘Requires Improvement’. We found the service required improvement in how it kept people safe, was responsive to their needs and how it was led. We also found a breach in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to governance and how the service managed.

The provider sent us an action plan outlining the improvements they intended to make. At this inspection we found some improvements had been made and the service was no longer in breach of the regulations. However we found some improvements were still required.

The date of this inspection was brought forward because we had received concerns about the management of people’s medicines, updating of risk assessments and the amount of activities available to people.

There was no 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.

The previous registered manager left the provider’s employment shortly after our inspection and the service had been supported by an interim manager with support from another of the provider’s Registered Manager’s and the Sheltered Housing and Care Services manager. The provider had made robust attempts to recruit a new manager and one had been appointed in April 2017. They officially joined the service in June 2017 following a delay in part of their application process. This person had begun their application to register with us.

People received medicines from staff who were trained; however some medicines were not always administered correctly and record keeping was not always accurate. For medicine taken ‘as required’ (PRN), guidelines were not available to tell staff when people needed this.

Risks to people’s safety had been identified by staff and ways to manage and reduce these risks were mostly in place to ensure a consistent and effective approach was taken. Staff were knowledgeable about people’s risks and how to support them safely.

Care records contained information for staff to help them provide personalised care, however updated information, that staff needed, was not always clearly recorded. The provider was actively addressing this at the time of our visit.

Most people told us there were enough staff to provide the support they needed and the provider assessed staffing levels daily to ensure there were sufficient staff available for people. We saw sufficient staff were available to support people and keep them safe.

Checks were carried out prior to staff starting work to ensure their suitability to work with people who used the service. New staff received an induction into the organisation, and completed relevant training to support them in meeting people’s health and care needs.

Staff had a good understanding of what constituted abuse and knew what actions to take if they had any concerns. People and relatives told us staff were caring and had the right skills and experience to provide the care required. People were supported with dignity and respect and people spent their time how they wanted to. Staff encouraged people to be independent.

Staff understood the principles of the Mental Capacity Act (2005) and how to support people with decision making. People told us they had enough to eat and drink. They enjoyed the meals provided and special dietary needs were catered for. People were assisted to manage their health needs. Referrals to other health professi

We carried out this inspection on 6 October 2016 and it was unannounced.

Alexandra House provides care for up to 36 older people in Solihull. At the time of our inspection there were 35 people living at the home. Some people were living with dementia.

A registered manager was in post and had been in the role for almost two years. This person was absent on the day of our visit. 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 could not be sure people who used the service were safe. Risks to people’s safety had been identified by staff, however ways to manage and reduce these risks were not always documented to ensure a consistent and effective approach was taken.

Care records contained information for staff to help them provide personalised care, however some information that staff needed was conflicting or missing about people and how they should receive their care.

There were enough staff to care for the people they supported however some concerns were raised about staffing levels at night. Checks were carried out prior to staff starting work to ensure their suitability to work with people who used the service. New staff received an induction into the organisation, and they completed training to support them in meeting people’s health and care needs.

Staff had a good understanding of what constituted abuse and knew what actions to take if they had any concerns.

People and relatives told us staff were caring and had the right skills and experience to provide the care required. People were supported with dignity and respect and people were given a choice in relation to how they spent their time. Staff encouraged people to be independent.

People received medicines from staff who were trained however medicines were not always administered correctly. For medicine taken ‘as required’ (PRN), guidelines were not always recorded to tell staff when people needed this.

Staff understood the principles of the Mental Capacity Act (2005) and how to support people with decision making, which included arranging further support when this was required.

People had enough to eat and drink during the day, were offered choices, and enjoyed the meals provided. Special dietary needs were catered for.

People were assisted to manage their health needs. Referrals to other health professionals were made when this was required.

Some people had enough to do to keep them occupied. There were limited activities arranged for people living with dementia.

People were given the opportunity to feed back about the service they received through surveys. Meetings for people and relatives were held.

People knew how to complain if they wished to, however told us they had no complaints. The provider was aware of their responsibilities in relation to managing complaints received about the service.

The provider did not have effective systems in place to identify areas that required improvement and to assure themselves that people received a quality service.

Staff had mixed views about the management of the home. Some staff did not always feel they could raise concerns or that these would be listened to. There were some formal opportunities for staff to feedback any issues or concerns at team meetings and in one to one meetings.

Checks of the environment were undertaken and staff knew the correct procedures to take in an emergency.

We had received the required notifications to enable us to monitor the service. The provider was able to tell us which notification we were required to receive such as safeguarding referrals and of serious injuries.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can s

We visited Alexandra House to follow up concerns we found when we carried out an inspection on 24 June 2014. At this inspection we set compliance actions as we had concerns the systems in place that monitored the quality of service were not effective.

At this inspection we found improvements had been made where we previously had concerns. We spoke with the temporary manager who had been managing the service for three weeks at the time of our visit. They explained to us the steps they had taken to improve the effectiveness of the audit system. We spoke with the Care Services Manager, two team leaders and one member of care staff about the quality checks and audits they completed.

We spoke with one person who lived at Alexandra House and asked them if their views were listened to. This person told us they were. They said: “I have a better greenhouse now because the other one needed replacing.”

We saw people and relatives had been involved in meetings and any improvements or changes had been considered and put in place where required.

The provider used quality assurance questionnaires to gather the views of people and relatives of people who used the service. Where suggestions were made we saw actions had been taken that led to improvements.

At the time of this inspection the registered manager was not the person named in this report.

This inspection was completed by one inspector. We spoke with five people and two relatives of people who used the service. We also spoke with the registered manager, two senior care staff and a cook. During our inspection we also spoke with a district nurse who was visiting a person who used the service. The evidence we collected helped us 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 we observed, the records we looked at and what people using the service, their relatives and staff told us.

If you want to see the evidence that supports our summary, please read the full report.

Is the service safe?

People we spoke with told us they felt safe. One person we spoke with said: “Oh yes, the staff are really good”. Another person told us: “I can lock my door if I want but I don’t because there is no need.” Both relatives we spoke with said they were pleased with the support and care their relatives received.

The provider and staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered manager and staff were able to describe when an application should be considered and who should be involved in the process. We saw one person’s care records where a DoLS application had been made and approved. The registered manager had involved this person’s family and sought appropriate guidance from other health care professionals. We saw records that showed a number of staff had received training in mental capacity. The registered manager told us further MCA and DoLS training was planned.

The home was clean and tidy with no unpleasant odours. The registered manager had cleaning schedules in place which made sure people’s rooms and communal areas were regularly cleaned. People and relatives we spoke with told us they had no concerns about the cleanliness of the home or their relatives’ room. One relative said: “I think the standard of cleanliness has gone up.”

We found equipment was maintained and regularly serviced. We found the provider carried out regular fire checks and ensured people and staff knew what to do in the event of an emergency.

We saw employment records that showed the provider had an effective system in place that made sure people received care from staff that were suitably qualified, experienced and fit for this work.

We looked at a variety of records. Examples of the records we looked at were people’s care plans, risk assessments, daily records, audits and quality questionnaires. We found these records were available and were stored safely and securely.

Is the service effective?

People had an individual care plan which explained what their needs were. Risk assessments were reviewed and identified current risks. We found two examples where the care records did not reflect people’s current health needs. The registered manager and senior staff member told us they were aware of this and would be seeking assistance to rectify this issue. We spoke with two relatives who told us they wanted to be involved in their relative’s care planning but had not been consulted.

People had access to health care professionals which supported their health care needs.

We found staff had received the necessary training that enabled them to provide suitable and appropriate care for people.

Is the service caring?

People were supported by staff who provided care at people’s preferred pace. Staff were kind and attentive and responded appropriately to people’s requests. Staff promoted individual choice and supported people who wanted to remain as independent as possible. We found individual wishes were taken into account.

Is the service responsive?

People received help and support from other health professionals when required, such as doctors, diabetic specialists and district nurses.

People were supported to participate in activities inside and outside of the home. At the time of our inspection people listened to music and watched Wimbledon tennis on the television in the communal lounge. We also saw one person was doing some gardening. This person said: “I love it out here; I do it as often as I can.”

The service had some systems in place to monitor the care provided to people although they were not always accurate. We found the provider held residents meetings to seek the views of people who used the service although it was not always clear if improvements had been made.

Staff said they had a handover at the start of each shift to update them of any changes in people’s care needs since they were last on duty. Staff told us this helped them understand people’s current care needs and what levels of support people needed.

Is the service well led?

The service did not have an effective system in place that assured them of the quality of service they provided. The service completed some checks and sought the views of people who used the service. However, there was little evidence that supported what actions had been taken that led to improvements.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people receive a quality of service.

There were thirty six people living at the home at the time of our visit. We spoke with four of these people, two relatives and the staff that were supporting them.

We observed the care and support being provided to these people. We saw that staff supported people in a respectful manner and that they were available at the times that people needed them. Staff offered people choices of how and where they wanted to spend their time. A person using the service told us "If I need help with anything I ask the staff and they sort it out for me."

People told us that they were happy with the choice and quality of food provided. The relative of a person using the service told us "My relative’s meal is pureed and it is good that all of the portions are pureed separately. This encourages them to eat well."

People told us that they felt safe living at the home and that they or their relatives would speak to the manager or staff if they had any concerns. The relative of a person using the service told us "If we have any slight problem the manager sorts it out, no messing about. They are very helpful."

Systems were in place to monitor the quality of service provided at the home. People using the service and their relatives were involved in this. The relative of a person using the service told us "I would give this place 110%."

We inspected Alexandra House in July 2012 and found the provider was not complying with the regulations about providing care, treatment and support that met people's needs. We told the provider they must make improvements and they sent us an action plan telling us what they were going to do.

We inspected Alexandra House again on 29 November 2012 and found evidence of improvement. We saw that simple summaries of people's needs had been produced for staff to follow at a glance. Processes had been put in place to ensure care plans were reviewed regularly to ensure they had been updated and remained relevant to people's changing needs. The provider must ensure the new review process is implemented robustly to ensure any discrepancies within care plan are identified so they provide staff with clear information on how to deliver care safely.

We carried out this inspection to check on the care and welfare of people using the service. We visited Alexandra House on 12 July 2012. There were 34 people living in the home at the time of this visit. No one knew we would be visiting. We spoke to three of the people who lived there, two visiting relatives, four staff members and the caretaker manager. We spent time observing how people were supported by staff. We looked at the records of two of the people who lived there and sampled staff records.

The home was clean and tidy although some of the furnishings were tired and required updating. There were no unpleasant odours. One relative said, "The home is clean and nice."

People told us they liked living in the home. One person said, "The food is good. The staff are good. I have no complaints."

We saw staff interacted with people in a warm and friendly manner. People were supported to make choices and their decisions respected. One relative told us, "They treat people as individuals."

We saw care plans were detailed. Staff knew how to support the people who lived there. However, some care plans had not been updated and important information linked back to the plan itself. This created a potential risk to health and wellbeing.

Staff had received training in safeguarding. They knew what to do to ensure people were safeguarded from abuse and harm.

There were adequate numbers of staff with relevant qualifications and training to support people.

There were systems in place to monitor the quality of the service provided by the home. There was not always evidence that people's suggestions as to the quality of service provided had always been assessed and responded to.