Alexandra House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for the service under this provider. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to people’s safe care and treatment and safeguarding.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Whilst the registered manager had some oversight of the service, action was not always taken to improvement the safety of the service. For example, we found limited action had been taken to improve pressure area care following a serious incident. We also found the same issues were reported on and found repeatedly, with little action taken to improve the safety of the service. Failure to implement lessons learnt increased the risk of harm to people.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. Whilst staff told us people were assessed prior to admission we found some people had no care plans in place for care staff to follow. Staff told us this was on the electronic system; however, care staff were not trained in this system and had no access to it. For example, a person with moving and handling needs had no care plan or risk assessment available to care staff. This meant staff had no guidance in how to safely support people. We also found staff did not always implement guidance from external healthcare professionals. For example, a person had been reviewed by the tissue viability nursing team and had instructions in place to promote wound healing. This review included specific time intervals in which the person should be repositioned. We found on several occasions the person was not supported to reposition in line with their assessed need. Failure to follow and implement guidance increased the risk of poor wound healing and further pressure damage.

The provider did not have robust systems in place to protect people from the risk of abuse. We found staff did not always recognise incidents as safeguarding concerns. This meant people were at an increased risk of abuse or neglect. For example, we observed some staff to use unsafe moving and handling techniques to support a person. We also found some people were ignored by staff, this included someone asking for help. Furthermore, we found most people needed support with oral hygiene such as assistance to brush their teeth that they had not been supported with. We found that all people’s toothbrushes were very dry meaning staff had not supported them in this area of care. Staff failed to recognise this as neglect. We fed our concerns back to the provider who took immediate action. Whilst processes and staff knowledge needed further work to ensure all people were protected from the risk of abuse, all the people we spoke with told us they felt safe living at Alexandra House. A person we spoke with said, “I feel very safe here, there is always people about they are all very helpful. I would go straight to [staff name] and talk to them, they are easy to talk to and always have time.” However, many people living at Alexandra House were unable to share their views and communicate any safety concerns to us, therefore we spent time observing people and staff interactions. Our observations raised safeguarding concerns for people unable to communicate their own needs.

The provider did not always ensure staff supported people safely. We found staff did not always have clear guidance in place to ensure people were supported in a safe way and according to their needs. For example, a person who regularly became distressed because of a medical condition had no care plan in place to guide staff in how they should support the person to minimise periods of distress. We also found where a person was at a significant risk of falls, there was no falls risk assessment in place. This meant staff had no guidance to support the person safely. Whilst people who spoke with us told us staff were kind and supported them safely, our observations did not support this feedback for all people living at Alexandra House. For example, whilst people told us staff helped them to move safely using equipment, we observed one person to be moved unsafely. We also found people who needed equipment to move were not always supported to access their equipment, as we found many walking frames to be left in people’s bedrooms whilst they were sat in the lounge. This meant people could not safely move around the home which placed them at risk of harm. Furthermore, we observed staff had implemented equipment unsafely. We observed a person with bed rails in place who was attempting to climb over the bed rails. This increased the risk of the person falling over the bed rails or becoming trapped in the bed rails. We fed this back to the provider who took immediate action. Failure to ensure risks were managed placed people at risk of avoidable harm.

The provider did not ensure risks associated with the environment were managed to protect people from harm. We found many radiators throughout the building in both communal areas and people’s bedrooms to be very hot without any protective covers. This increased the risk of burns to people living with a sensory or cognitive impairment. We also found furniture, including heavy draws and shelving units in bedrooms and communal areas had not been fixed to the walls. This meant furniture could tip or fall, which increased the risk of harm to people. Risk associated with the kitchen had not been managed to ensure food preparation areas remained safe. The Food Hygiene Standard Agency had completed a visit on 8 March 2024 and identified improvements to ensure they remained in line with legal requirements. We found not all the improvements had been completed. For example, a freezer still had a very worn and dirty seal, and a refrigerator continued to have corrosion to its door. We also found the kitchen to be unclean and food to be stored unsafely. This placed people at risk of harm due to poor food storage. People gave us mixed feedback about their environment, some were happy whereas others told us improvements were needed. The provider was receptive to our feedback and acted, they also acknowledged improvements were needed and told us a full programme of refurbishment was planned.

The provider did not always make sure staff were deployed effectively to ensure people received timely care and support. We found on several occasions there were no staff upstairs at Alexandra House despite people being present upstairs. We found one person who was unable to use their call bell to request support, to be left alone for long periods of time. We also found during morning staff handover there were no staff present to supervise and support people, as the night staff team had left the building, and the day staff were in the nurse’s office. We fed this back to the provider who took immediate action. People gave us mixed feedback about staffing levels. For example, one person told us, “There is always someone around,” whereas another person told us, “I don’t ever think there is enough staff, I press my buzzer for them, but they must be busy, as it’s too late by the time they come.” Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had also had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people. The service employed some nurses. These nurses were registered with the regulatory body (The nursing and midwifery council). The management team completed regular checks to ensure their nursing registration was maintained.

The provider did not ensure infection prevention and control measures in place were effective. Parts of the home were in a state of disrepair meaning it could not be cleaned effectively. We observed paint to peeling off walls in communal areas and in people’s bedrooms. We found significantly chipped door frames and skirting boards in communal areas and service user’s bedrooms. We also found furniture was dirty, tables and chairs were worn which meant they could not be cleaned effectively. We found processes in place to identify and improve infection prevention and control practices to be ineffective. For example, we observed people were not supported to wash their hands before eating, this had been identified consistently within a dining audit since May 2024 with little action being taken to improve people’s experience. People told us staff worked hard to try and keep the home clean and tidy.

The provider did not ensure medicines were managed safely. We found topical medicines were not stored safely. We found topical medicines which were accessible and unsecured in people’s bedrooms. This placed people living with dementia at risk of harm if they had access to these products and ingested them. We found topical medicines were not always dated with an open date. Which meant staff did not know if these were safe or effective to use. We found records in place relating to the administration of topical medicines to be poorly completed. This meant staff and external healthcare professionals were unaware if the topical medicine had been administered. People did not always receive their prescribed medicines on time. We found a person who required time specific medicines to receive these 3 hours late. We also found people received their pain relief late. This placed people at an increased risk of harm. People told us staff kept them informed of the medicines and if any changes were made by the prescribing professional.