Archived: Alexian Brothers Care Centre

Updated 12 May 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 16 February 2017 and was unannounced. The inspection team consisted of three adult social care inspectors from the Care Quality Commission (CQC) and two specialist advisors. A specialist advisor is someone with appropriate skills and experience in a field related to the service provided at the location to be inspected. One specialist advisor for this inspection had skills in nursing care and the other in social work.

Prior to the inspection we looked at information we held about the service such as notifications, safeguarding concerns and whistle blowing information. We also received a provider information return (PIR) from the provider. This form asks the provider to give us some key information about what the service does well and any improvements they plan to make.

During the inspection we spoke with 18 people who used the service, eight relatives and one other visitor. We also spoke with two members of care staff, the chef, the hairdresser, two activities coordinators and the registered manager. We observed care during the day and reviewed records at the home including five care files, two staff personnel files, meeting minutes, training records, health and safety records and audits held by the service.

Updated 12 May 2017

The unannounced inspection took place on 16 February 2017 and had been brought forward due to some concerning information received.

The Alexian Brothers Care Centre is a 74 bedded care home, providing long-term care for older people who require residential support and nursing care. The home is set within mature grounds, in a secure, gated development. On the day of the inspection there were 68 people using the service.

There was a registered manager in place 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.

The last inspection was undertaken in March 2015 when the service was rated as Good overall. During this inspection we found four breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 with regard to safe care and treatment, dignity and respect, complaints and good governance.

You can see what action we told the provider to take at the back of the full version of the report.

People told us they felt safe at the home and we found the building and grounds to be secure.

Safeguarding policy and procedures were in place and staff were being given extra support in the area of safeguarding to help ensure timely reporting of incidents. Staffing levels were sufficient to meet the needs of the people who used the service. Staff were recruited safely through a robust recruitment programme. There was a robust induction programme and a comprehensive programme of training for all staff.

Medicines systems were robust and safe. Oxygen cylinders were not always used and/or stored safely. The fire risk assessment was out of date and some of the radiators were extremely hot and posed a potential risk to people who used the service. The registered manager agreed to ensure a new fire risk assessment was implemented. Radiator covers were installed immediately to the affected radiators. Water temperatures were tested and some were found to be very hot, presenting the risk of scalding to people who used the service.

The environment was cluttered in places and a number of notices made the environment feel clinical. The premises could have been enhanced with fewer notices, more dementia friendly signage and better lighting to help people orientate around the home.

We observed the mealtime experience on two of the units. Although there could have been some improvements to how the tables were set, we saw that staff were attentive and assisted people respectfully when needed. People told us they enjoyed the food and were given plenty choice. Food and fluid charts were not all completed as required.

The home was working within the legal requirements of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS). However, recording of capacity could have been improved.

People who used the service, and their relatives, were positive about the kindness shown by staff. We observed friendly and respectful interactions throughout the day.

We saw a few instances throughout the day where people’s dignity had been compromised. Confidentiality was also compromised by people’s personal records being kept outside people’s rooms where any visitor to the service could potentially view them.

People who used the service felt the staff were responsive to their needs and they were given choice, though some felt staff rushed them.

There were a range of activities on offer. People from the community joined in the mass at the chapel, attended the lunch club and used the hair salon. This gave people in the home the opportunity to mix with people from the locality.

No evidence was available to show that complaints were responded to appropriately. People told us they would be able to raise an issue if they needed to. The service had received a number of compliments.

People told us the management were approachable and staff felt well supported. Supervisions and team meetings took place on a regular basis.

A number of audits and checks were regularly carried out by the service. Where issues had been identified, we found little evidence that these issues had been addressed.

The service had good links with the local community and worked in partnership with other organisations to share good practice.