Queen Alexandra Cottage Homes

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• 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

Systems were in place to help ensure people remained safe. People were protected from the risk of harm and abuse. Staff knew people well and understood the risks associated with their care. There were sufficient and appropriately trained staff, who had been safely recruited to support people. Some improvements were needed to aspects of record keeping including mental capacity assessments and accidents and incidents. We also recommended the provider review staffing levels throughout the day as staff reported times when they were particularly busy. Following the assessment, the provider told us how they would be reviewing and developing these areas.

This service scored 75 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff told us how they would identify and report any safeguarding concerns. One staff member told us, “I would have to report it, it would go against the resident and against the home if I didn’t. If I didn’t report I wouldn’t be doing my job.” Another staff member told us how they would report concerns but if no action was taken, they would report this further. They explained that they were aware this was their responsibility and although they couldn’t tell us who they would contact they said the information they needed was displayed in the staff room.

People told us they felt safe at the home. They said they were able to discuss any concerns with staff or their relatives. One person named the staff member they would speak to, another person said, “I would tell my [relative] and they would talk to staff.” A further person told us, “If I was worried, I would talk to staff. me and my [mouth], we say everything.”

Improvements were needed to some aspects of processes. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Where needed, appropriate legal authorisations were in place to deprive a person of their liberty. The registered manager had oversight of DoLS applications, authorisations, and conditions. Whilst we found the service was working within the principles of the MCA mental capacity assessments and best interest decisions had not been recorded to demonstrate how decisions had been made and who was involved. There was an MCA policy which stated best interest decisions records are kept in people’s files. There were no best interest decisions recorded. Although some care plan audits had been completed these did not identify if mental capacity assessments and / or best interest decisions were required. We discussed this with the nominated individual and managers as an area that needed to be improved. Following the inspection, we were told the service was receiving support from the local authority to develop this aspect of their record keeping.

Staff knew people well and were able to tell us about the risks associated with people’s care and how they supported them safely. This included pressure area management, mobility, and specialised diets. Staff were able to tell us what actions they would take if an accident or incident occurred, for example, someone had a fall. This included, calling for help, reassuring the person, making them comfortable, if safe to do so and assess for obvious and immediate injuries. They told us they would complete an incident form and record what happened in the daily notes.

Staff involved people in their care and support and allowing them time to make their choices and remain safe. One person was sitting in the corridor, staff approached to make sure they were ok. The person was unsure what they wanted to do so staff suggested a cup of tea and person agreed. The person walked to the kitchen with staff and then into lounge to have their drink. They chose to sit on their own but other people and staff were present. Some people had pressure mattresses to prevent pressure damage. These were checked daily to ensure they were set appropriately for each person. Staff were aware who was responsible for this. Whilst we did not observe people having their positions changed, to prevent pressure damage, staff were heard discussing when people needed to be re-positioned. Moving and handling equipment was in place for those assessed as needing it. One observation indicated that staff were using this appropriately, explaining to the person and maintaining their dignity. We saw people who required the use of mobility aids were supported to use them appropriately. Some people required specialist diet, thickened fluids, pureed foods. Staff were aware of these risks and supported people appropriately. When people required thickened fluids, staff recorded the amount of fluid given and thickener given. Bed rails and sensor mats were used when indicated. Where people had capacity, they had been included in making the decisions to use them. Where people lacked capacity, their involvement in the decision was recorded, however the mental capacity act had not been followed (see safeguarding section of this report).

Improvements were needed to some aspects of processes. Care plans for wound care did not include all details about the wound. Photos of a wound had been taken but there were no measurements recorded and no information about how the wound had occurred. Accidents and incidents were recorded. However, the recording around this was inconsistent. For some there was a lack of detail about actions taken to prevent a reoccurrence. There was no analysis of accidents and incidents either individually or across the home to show themes and trends, for example, times of day, types of accident or incident. Most care plans reflected individual risks with guidance how to support people safely. This included the risk of falls, moving and handling, nutrition, and pressure area damage. Staff showed us how the electronic systems informed them when a person needed their position changed. Records showed that people’s positions were changed appropriately. One staff member explained that if they were delayed in changing the person’s position then the electronic device would alert staff to this. Staff had a good understanding of how to use the electronic plans to support people safely. Handovers were used to update staff at each shift change. There was also a daily report from the heads of department to identify any changes or where there maybe shortfall in care provision. There was a diary which included details of people’s appointments and prompts for wound care. Handover included diary checks to ensure all work required has been done.

People told us they were involved in managing their own risks whilst maintaining their independence. One person told us, “I am able to do whatever I want.” This person explained that if they required further support, they were able to ask staff and this support was given. People’s relatives told us their loved ones were supported safely. One relative described how they were involved in all aspects of their loved one’s care. This helped ensure they received the safe care and support they both needed and chose.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed feedback from staff about staffing numbers. One staff member said, “We work together as a team to support each other.” Another said there is not enough some afternoons. Another staff member said at night there is 2 care staff and 1 nurse which makes it busy at the start of the night. Most staff members said they did not think management took into account dependency of people or the amount of people that needed support from 2 staff. Staff said there were times on each shift when they needed an extra staff member working, for example early evening and afternoons. They spoke about not attending to people in a timely way and difficulty in finding colleagues when two staff were needed. This is an area to that needs to be continually reviewed. We received conflicting information about staff supervision. This is an area that needs to be improved to ensure all staff are supported to receive supervision that is beneficial to them and the service. We were told that previously staff were offered supervision and were able to decline. However, since January 2024 all staff are required to have supervision. This had commenced. However, discussions with staff, demonstrated this was variable. Some staff received supervision, others had declined because it was not useful, they didn’t feel listened and issues raised were not addressed. Other staff felt they were not being supervised by an appropriate person. Staff told us they received training. “Training wise would like some more practical things, further courses on (for example) dementia training.” “We would like practical strategies. We can come across unpredictable behaviours every day. Would also like practical refresher on the importance of PPE.”

People told us staff were kind and caring. Relatives were very happy with the care received and said it was appropriate to people's needs. One relative said, “We know she’s safe, well looked after and cared for.” Another relative told us, “[Name] is very happy with the care she gets, there’s always plenty of staff who are friendly and helpful we’ve no complaints about level of care she is getting." There was mixed feedback from people about the length of time they waited for a response to their call bells. One person said, “Sometimes I have to wait a long time.” Another told us, “They come when I call.” A further person told us they were fairly independent, but staff would support them if and when they needed it. One relative said, "Sometimes they are short staffed." They went on to explain that this did not impact the care their loved one received. All relatives told us staff always had time for them and to talk with them.

Staff appeared to work together well as a team. They were well organised with clear roles. It was busy however staff responded promptly to call bells. On occasions some bells took longer to be answered if staff were busy, but bells were not ignored. Downstairs staff appeared to have more time to attend to people and chat with them. However, downstairs staff also went to support upstairs staff at peak times. This was observed in the afternoon. Some people had pressure mattresses. These were checked daily to ensure they were set appropriately for each person. Staff were aware who was responsible for this. Moving and handling equipment was in place for those assessed as needing it. One brief observation indicated that staff were using this appropriately, explaining to the person and maintaining their dignity.

There were processes in place to determine staffing levels. The provider told us that an audit had been completed by an external organisation on dependency levels to determine staffing levels. Staff told us the current staffing levels did not fully reflect people’s dependency. This is an area that needs to be reviewed. There was a supervision program. We were told this had been reviewed and all staff now received supervision. This did not reflect the information given to us by staff. This needs to be reviewed to ensure changes made are effective and fully embedded into practice. There was a training program and we saw that not all staff had completed all the required training / updates. The manager told us there was oversight of training. Staff were sent reminders and if they did not complete the training this may lead to disciplinary action. The manager gave us examples of actions that had been taken. Relevant pre-employment checks were completed before staff started work at the home. This included references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.