Background to this inspection
Updated
4 May 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by 1 inspector.
Service and service type
Alvina Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Alvina Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 2 people who used the service about their experience of the care provided. We spoke with 3 members of staff including the registered manager, a manager and a support worker. We reviewed a range of records. This included 4 people’s care records and the medicines records for all the people who used the service. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures, records of complaints, quality audits, meeting minutes and improvement plans were reviewed. After the inspection, we continued to seek clarification from the provider to validate evidence found. We looked at the rota and training records. We received feedback by email from 1 member of staff. We emailed 4 healthcare professionals but did not receive a response.
Updated
4 May 2023
About the service
Alvina Lodge is run by a small private organisation. The provider owns and manages one other care home. One of the owners is also the registered manager for Alvina Lodge. Alvina Lodge is a care home providing personal care to up to 5 people with mental health needs. At the time of our inspection there were 4 people using the service.
People’s experience of using this service and what we found
The staff had not always received a thorough induction into Alvina Lodge when they had worked at the provider’s other service. Staff did not always receive regular appraisals. Some staff told us they did not always feel supported or valued by the management team.
The staff received online training but had not received specific training in techniques to deal with people who had difficulty managing their emotions and anxiety.
People’s medicines were managed safely to help ensure people received their medicines as prescribed and in line with national guidance. However, a person’s medicine to be given as required was not included on their medicines administration record. This was addressed with the pharmacist following our inspection.
The provider relied on temporary (agency) staff on most shifts. However, there was evidence agency staff were regular and had received an induction into the service or training appropriate to the needs of people who used it.
Staff were recruited appropriately.
The staff undertook regular daily safety checks. Lessons were learned when things went wrong. The management team had systems in place to manage incidents and accidents and prevent re-occurrence of these.
Risk assessments contained guidelines and plans for staff on how to minimise risks for people using the service.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People’s needs were recorded in their care plans and met. Staff knew people’s needs and how to meet these in line with their care plans.
People told us they felt safe when receiving care. The provider had processes in place for the recording and investigation of complaints and incidents and accidents.
The registered manager and senior staff were responsive to and worked in partnership with other agencies to meet people’s needs.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Alvina Lodge on our website at www.cqc.org.uk.
Rating at last inspection
The last rating for this service was good (published 5 December 2017).
Why we inspected
The inspection was carried out based on the date of the last comprehensive inspection.
We have found evidence that the provider needs to make improvements. Please see the effective and well-led sections of this full report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.