Alexandra Court Care Centre

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. The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how this could be achieved. Whilst there were policies and processes in place to keep people safe, some processes in relation to the Mental Capacity Act 2005 were not followed closely. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care was not always delivered in line with their care plans. Whilst there were sufficient members of staff on shift, deployment of staff could have been managed more effectively around mealtimes. Members of staff were often task focussed and did not engage with people proactively. The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

People’s care was not always assessed and reviewed effectively and, as a result, there were instances where care was not always delivered in line with people’s care plans. There were inconsistencies in how people’s fluid intake was monitored and reviewed. We observed people’s mealtime experience and found some improvements were required. People’s care plans and daily care notes did not always accurately reflect care provided. There were inconsistencies in recording of repositioning for people and there were also gaps in recording continence care for people.

Members of staff were task focussed and did not always interact with people or have conversations with them. There was limited evidence of people being supported to get involved in activities. We did observe an activity session taking place on the day of inspection but information from care notes did not evidence activities and engagement were the norm. Staff morale in the care home was low as a result of inconsistent management and leadership.

Care was not always person-centred and members of staff were focussed on completing tasks rather than on people. Staff did not always involve people in decisions about their care or tell them what had changed as a result. People's families told us they did not have access to people's care plans and did not feel listened to or involved. People had ReSPECT forms in place but conversations and discussions had not always taken place with people and their families about end-of-life planning.

The provider’s core values were clearly articulated and displayed on their website with the organisational vision defined as ‘Kindness is key’. Our observations in the care home and people’s experience highlighted inconsistencies in understanding these values at an operational staffing level which impacted on the quality of care and support provided. At the time of the inspection there was limited confidence in the leadership and management in the care home. When we spoke to people and their families about the management team, the responses were mainly negative about the style of management and delivery of care. Oversight and governance by the local management team was not effective. Regular management walkarounds, audits and quality checks were not completed consistently. The provider had developed new governance documents which were in the process of being implemented and reviewed. These new governance systems needed to be embedded, reviewed and sustained by the new management team.