42 Alexandra Road improved from Requires Improvement to Good across both inspected key questions (Safe and Well-Led), demonstrating effective progress since the February 2023 inspection. The service showed strong safeguarding, medicines management, recruitment practices, and governance, with only minor issues around infection control policy currency and recording of completed improvement actions.
Concerns (3)
minorInfection control: “We were not totally assured that the provider's infection prevention and control policy was up to date.”
minorGovernance: “The registered manager told us about their progress with actions, but needed to record when they were completed.”
minor
Communication with families
: “A relative felt communications from the office could be clearer sometimes.”
Strengths
· Staff received safeguarding training updated yearly and understood their duty to report concerns.
· Safe staff recruitment processes with required pre-employment checks completed.
· Medicine administration records and topical cream charts were accurate, with staff competency assessed.
· Registered manager implemented a service improvement plan with defined outcomes and monthly audits.
· Staff workshop held to share learning from incidents and reduce recurrence.
42 Alexandra Road improved significantly from its previous Inadequate rating, exiting Special Measures after addressing 10 prior regulatory breaches, but remains Requires Improvement overall due to ongoing gaps in medicines audit robustness and inconsistent communication with families about carer changes. Safe and Well-led remain Requires Improvement while Effective, Caring and Responsive are all rated Good.
Concerns (6)
moderateMedication management: “Topical cream charts for 4 people had not all been updated following changes.”
moderateMedication management: “Staff had recently started leaving a person's morning medicines out for them to take as per their verbal instructions. The registered manager understood a written risk assessment should have been in place prior to this change.”
moderateGovernance: “Further time was required, to demonstrate the medicines audit process was fully robust and embedded.”
moderateCommunication with families: “Some relatives reported they were not always aware of who was replacing their loved one's live-in carer when they took a break or if they planned to return, which caused anxiety.”
minorRecord keeping: “Occasionally they referenced an incorrect pronoun for the person.”
minorGovernance: “The provider's last CQC report was not displayed either in their office or on their website at the start of the site visit as legally required.”
Strengths
· People and relatives reported staff were kind, compassionate and respectful, with feedback including 'The carers are very nice and kind' and 'Very happy with the current carer'.
· Safeguarding processes improved: staff completed training, maintained body maps, recorded financial transactions, and the registered manager shared investigation findings with staff for learning.
· Care plans rewritten to be detailed, individualised and personalised, reflecting people's choices, preferences and personal histories.
· Staff received regular one-to-one and group supervisions, with frequency reflecting the revised supervision policy.
· Registered manager promoted a more positive and open working culture and engaged with external agencies to drive improvements.
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
42 Alexandra Road (Virtue Care Ltd) was rated Inadequate overall following a July 2022 inspection, with ten regulatory breaches spanning medicines management, staffing, safeguarding, recruitment, consent, dignity, person-centred care, nutrition, governance, and failure to notify CQC. The service was placed in special measures, with conditions imposed on the provider's registration, as widespread leadership failures left people at risk of avoidable harm and the provider unable to demonstrate a credible improvement plan.
Concerns (17)
criticalMedication management: “A member of staff had administered people's medicines prior to the completion of their medicines competency assessment.”
criticalMissed or late visits: “over a 45 day period I have had 28 missed visits for two carers [only one came] and two missed visits for two carers [no one came at all]”
criticalStaffing levels: “The failure to deploy sufficient numbers of staff to meet people's care needs as commissioned was a breach of regulation 18(1)”
criticalSafeguarding: “Two of them both reported their relatives had been 'force fed' by staff. CQC reported these incidents to the relevant local safeguarding authorities.”
criticalStaff competency: “Three care staff spoken with were not familiar with the provider's safeguarding policy and relevant information, such as the need to record any damage to service users skin on a body map.”
criticalCare planning: “Five relatives said the person either lacked a care plan or it was incorrect… 'There is no care plan in the house.'”
criticalPerson-centred care: “The failure to ensure people's care plans were personalised to their needs, preferences and interests was a breach of regulation 9.”
criticalConsent / capacity: “The MCA form staff used to assess if people lacked capacity, was incorrect. It made reference to multiple decisions, rather than being decision specific.”
criticalIncident learning: “Staff did not all understand their responsibility to raise concerns, record safety incidents and near misses… neither of these injuries were logged.”
criticalGovernance: “The registered manager had failed to inform CQC as required of a person who had sustained an ungradable pressure ulcer in May 2022.”
criticalInfection control: “A person's risk assessment noted PPE was to be worn at all times during personal care. The person's carer told us, they had 'no gloves and aprons'.”
criticalLeadership: “The registered manager did not appreciate the extent or depth of the failings and did not have a robust plan to improve the standard of care.”
moderateSupervision / appraisal: “Two staff had no evidence of supervision or spot checks and two staff had evidence of one supervision each on the day they commenced work.”
moderateStaff training: “some haven't known how to turn on the oven… a carer did not know how to apply their continence pad and they had to instruct them.”
moderateRecord keeping: “Some people's care records were inaccurate, lacked dates and attention to detail and contained conflicting information about their care.”
moderateComplaints handling: “I have given up trying to complain, nothing happens, I ring up but you are just ignored… if you ring them nothing much changes.”
moderateCommunication with families: “The person's relatives had told us they were extremely unhappy about the care provided. The feedback form did not provide an up to date record of their views.”
Strengths
· Staff had completed safeguarding training and when the registered manager was informed of events by staff, they took appropriate action.
· Staff liaised with professionals such as occupational therapists, physiotherapists and district nurses about people's risks and issues.
· Staff had completed training in areas such as first aid, moving and handling, fire safety, dementia care, equality and diversity, food hygiene and end of life care.
· The registered manager ensured a range of risk assessments were completed covering environment, falls, mobility and fire.
· People and relatives generally reported that frontline care staff were kind and nice, with issues attributed to management rather than carers.
Quality-Statement breakdown (18)
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Preventing and controlling infectionInadequate
safe: Learning lessons when things go wrongRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
42 Alexandra Road, a domiciliary care agency, was rated Requires Improvement overall following a focused inspection of Safe and Well-Led, driven by concerns about medicines management, missed visits, incomplete records, and governance failures including two unreported notifiable incidents. Breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) were identified, resulting in a downgrade from the previous Good rating.
Concerns (10)
criticalMedication management: “Staff had not always documented the administration of a person's medicine on their medicine administration record (MAR). One staff member told us, 'I was a bit relaxed'.”
criticalMedication management: “Two people were prescribed medicines to be administered 'as needed.' There was a lack of written guidance for staff to enable them to understand when the person might require the medication.”
criticalMissed or late visits: “The provider did not have effective systems to mitigate the risk of missed calls. Staff had failed to arrive for a planned care call and they were not informed.”
criticalGovernance: “The provider had failed to notify CQC of two recent notifiable incidents at the time they occurred as legally required.”
criticalSafeguarding: “They were not able to demonstrate they had effectively addressed all of the concerns which arose from one safeguarding alert. This meant one of the issues carried on.”
moderateRecord keeping: “Daily care records for two people were incomplete and not all daily records for a third person were readily available.”
moderateRecord keeping: “One person's records contained the name of a person who was not their relative and another person's risk assessment noted their gender incorrectly.”
moderateCare planning: “Records confirmed one person was living with dementia, but their care plan lacked sufficient detail about how staff should meet their needs for social stimulation.”
moderateStaff competency: “A relative told us the staff member providing end of life care to their loved one lacked sufficient knowledge. When we spoke with them they could not recall this training.”
moderateStaffing levels: “One person told us, on occasions only one care staff was provided instead of two as commissioned. They had been assessed as requiring two staff to provide their care.”
Strengths
· Staff had completed safeguarding training and understood their responsibility to report concerns.
· The provider assessed potential risks to people and had measures in place to manage identified risks.
· Staff met infection control requirements including effective PPE use, testing, and up-to-date IPC policy.
· Staff meetings were held following incidents to share learning and reinforce guidance.
· The provider completed monthly audits of records, medicine records and staff recruitment.
42 Alexandra Road improved from Requires Improvement to Good across all inspected key questions (safe, effective, responsive, well-led), having remediated previous breaches of regulations 12, 17, and 19. The service demonstrated robust recruitment, medicines management, risk assessment, and governance processes, with consistently positive feedback from people and their relatives.
Concerns (1)
minorMedication management: “Staff recorded the administration of 'over the counter' topical creams for two of the seven people in their daily notes but not on their MAR.”
Strengths
· Robust staff recruitment processes including DBS checks resolved previous breach of regulation 19
· Electronic call monitoring system with 15-minute alert threshold ensuring visit punctuality
· Monthly audits of staff files, medicine records and daily records with tracked action plans
· People and relatives reported consistently positive feedback: staff understood care preferences and managed risks well
· Staff competency in medicines administration assessed and documented, resolving previous breach of regulation 12
Virtue Care was rated Requires Improvement overall following a May 2018 inspection, with a breach of Regulation 19 found due to inadequate recruitment checks and gaps in staff medicine training and supervision records. The service demonstrated strengths in caring practice, person-centred care planning, safeguarding awareness, and staffing continuity, but the quality assurance system lacked sufficient evidence to assure oversight of service quality.
Concerns (7)
criticalStaffing levels: “The provider did not follow their recruitment process to ensure they employ fit and appropriate staff.”
criticalRecord keeping: “None of the staff had any health check completed to ensure they were fit to carry out their role. All staff had gaps in their employment history which had not been explored.”
moderateMedication management: “Only one staff out of five had this training completed at the time of the inspection. Therefore, the provider did not adhere to medicine policies and procedures fully.”
moderateSupervision / appraisal: “People were supported by staff who did not have regular supervisions (one to one meetings) with their line manager...they could not evidence they recorded these conversations.”
moderateGovernance: “They were not able to evidence to us the work they have carried out to ensure their service was adequate and of good quality at all times.”
moderateStaff training: “Not all staff had medicine training and dementia care training and there was no information to indicate they were booked to attend it.”
minorIncident learning: “The registered manager did not demonstrate a good understanding of when the commission need to be notified.”
Strengths
· People felt safe in their homes and staff had good understanding of safeguarding responsibilities and whistleblowing procedures.
· No missed visits; staff arrived on time and informed people of any lateness; continuity of care maintained through consistent staffing.
· Care plans were individualised, regularly reviewed, and involved people in their planning.
· Staff treated people with kindness, respect, dignity and promoted independence.
· Staff communicated effectively with GPs, local authority, community nurses and other professionals to monitor health needs.
Quality-Statement breakdown (17)
safe: Recruitment practicesRequires improvement
safe: Medicines managementRequires improvement
safe: SafeguardingGood
safe: Staffing levels and missed visitsGood
safe: Risk assessmentGood
effective: Staff training and inductionGood
effective: Supervision and appraisalRequires improvement
Virtue Care was rated Requires Improvement overall at this April 2019 inspection, with three regulatory breaches identified covering unsafe medicines management, inaccurate and incomplete records, and insufficiently robust recruitment procedures. Caring was the sole Good domain, reflecting positive staff-client relationships, while persistent governance failures and an inability to close out audit actions from January 2019 underpinned widespread shortfalls across safe, effective, responsive and well-led domains.
Concerns (11)
criticalMedication management: “The provider had not completed a full assessment of people's medicine support needs as required by national guidance and their medicines policy.”
criticalRecord keeping: “The failure to maintain securely an accurate, complete, up to date and contemporaneous record for each person was a breach of Regulation 17.”
criticalStaff competency: “A staff member's file reviewed lacked both the date they completed full-time education and a full employment history dating back to when they had completed full time education as legally required.”
criticalGovernance: “None of the 20 identified actions on the audit had been signed off as complete. The provider was not able to demonstrate they would be able to complete all remaining outstanding actions.”
moderateMissed or late visits: “We saw on the 07 April 2019 there had been 16 late call alerts. There were five late calls by 11:10 on 8 April 2019.”
moderateCare planning: “People's electronic care plans were not always fully person centred or individualised. Records showed three people enjoyed identical activities.”
moderateInfection control: “Two people told us staff washed their hands after they had removed their gloves but not before they put them on.”
moderateConsent / capacity: “There was a lack of written evidence to demonstrate people had signed them. The provider had identified this issue in their audit of 12 January 2019.”
moderateEnd-of-life care: “Both people receiving end of life care felt well cared for...however, their care needs in relation to their end of life care had not been documented for staff's reference.”
minorComplaints handling: “The provider was not able to demonstrate there was an effective process for documenting people's verbal complaints and the actions taken.”
minorSupervision / appraisal: “The provider had since December 2018 commenced one to one staff supervisions...This process was still new and needed to be fully embedded and completed three monthly.”
Strengths
· People overall reported positive, kind and caring relationships with staff: 'The majority are smiley, chatty and create a positive vibe.'
· Risks to people had been assessed and mitigated, with written guidance for staff and relevant risk assessments in place.
· Staff had received appropriate training including medicines management, dementia care, safeguarding, moving and handling, and equality and diversity.
· People's privacy and dignity was upheld during care, with staff explaining how they respected people's dignity.
· The provider worked in partnership with local authority and clinical commissioning groups and ensured appropriate information sharing.
Quality-Statement breakdown (22)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Working in partnership with othersGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Continuous learning and improving careInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
effective: Nutrition and hydration support
Good
caring: Dignity, respect and privacyGood
caring: Promoting independenceGood
responsive: Person-centred care planningGood
responsive: Complaints handlingGood
responsive: Accessible Information StandardRequires improvement
well-led: Quality assurance and governanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Planning and promoting person-centred, high-quality care and supportRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement