Inspection on 12/06/06 for 25-27a Alexandra Road

This inspection was carried out on 12th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

25-27a Alexandra Road 27/11/07

25-27a Alexandra Road 31/01/06

25-27a Alexandra Road 02/06/05

25-27a Alexandra Road 16/03/05

25-27a Alexandra Road 07/09/04

25-27a Alexandra Road 27/01/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Alexandra Road (25/27a) Weymouth Dorset DT4 7QQ Lead Inspector Sally Wernick Key Unannounced Inspection 12th June 2006 9:00 Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Road (25/27a) Address Weymouth Dorset DT4 7QQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01305 760663 01305 770236 Dorset County Council Daniel James Crone Care Home 23 Category(ies) of Learning disability (23), Physical disability (3), registration, with number Sensory impairment (2) of places Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing levels must be those determined in accordance with guidance recommended by the Department of Health. To accommodate up to a maximum of 2 service users in the category of LD (E) at any one time. 31st January 2006 Date of last inspection Brief Description of the Service: 25/27a Alexandra Road is a care home providing a service to adults who have a learning disability. The home is located in Weymouth, a short distance from the town centre, and is owned and operated by Dorset Social Care and Health Directorate. Alexandra Road was built in the late 1970s and can accommodate up to 23 people, usually offering 21 permanent and 2 short-term care places. The home is split into units, accommodating between 4 and 9 service users in each unit. Each unit has a lounge, dining room, kitchen and their own bathroom and toilet. Each service user has a single bedroom. The home has special adaptations and equipment to meet residents various physical needs. These include ground floor bedrooms, walk in baths and adapted toilets. There is level access to the building. There is a garden to the rear of the property. Staffing is provided 24 hours a day and as well as providing personal care and support, service users are encouraged to be part of the local community by taking part in leisure and social activities. The fees charged in the care home are £521.76 per week. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and began at 9:00am on Monday, 12th June 2006. This was a ‘key inspection’ where the homes performance against the key National Minimum Standards was assessed alongside progress in meeting requirements made at the last inspection. The Registered manager assisted the inspector, as did other members of care staff. Methodology used included a tour of the premises, review of records and discussions with service users and staff. The inspector also reviewed the contact sheet for Alexandra road and documentation submitted by the registered manager in response to requirements made at the last inspection. The Commission for Social Care also sent questionnaires to the home for them to distribute amongst residents, relatives and visiting professionals. At the time of writing none have been returned. What the service does well: Alexandra road is a well run and managed by an experience team whose roles in the home are clearly set out. This ensures all aspects of life in the home are effectively covered. There is an atmosphere of openness with good working relationships between service users and staff. An increase in staffing hours means that service users are able to spend more time in the home doing activities of their choice. Alexandra road can accommodate up to 23 residents, the premises comprises of four different living units with between four and nine service users accommodated in a unit. Each unit has a small kitchen, dining room, lounge and bathroom and this gives the environment a homely feeling. There is a pleasant garden and service users where they choose are actively involved in its upkeep and maintenance. The home has a committed staff team who work hard to ensure improvements are made to resident’s quality of life. Staff work with small groups of service users who they get to know well. This ensures excellent continuity of care providing residents with a good level of personal care and support, which respects their personal preferences. Observation of practice in the home showed that staff spent most of their time with service users and it was clear good relationships had been formed. Staff spoken with enjoyed their work and felt well supported resulting in an enthusiastic workforce. A commitment to training from both staff and management ensures that the ongoing programme of development is able to meet the changing needs of residents. Residents spoke positively about their care and were particularly enjoying the new and wide-ranging opportunities afforded to them through increased staff hours. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 No new residents have been accommodated at Alexandra road since the previous inspection this standard has not therefore been inspected. EVIDENCE: Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service Alexandra road has a detailed care planning system in place, which ensures that staff has sufficient information to meet the needs of residents. Service users are encouraged to make choices and independent decisionmaking is promoted. Each person has a personal risk assessment on file with the aim of promoting independence. EVIDENCE: Each service user has a care plan generated from the care management assessment/care plan in line with a previous requirement. Three care plans were reviewed all were up to date and all included an “establishment task list”. This contained information about personal likes and dislikes, goals, personal care, social and therapeutic activities, health, safety, communication and selfcare. Each year individual goals are set and these are reviewed on a monthly Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 10 basis with a written review at the six-month stage. There was evidence that service users are involved in goal setting and where appropriate are supported by relatives and friends. Teachers, care managers and day care staff are invited to relevant reviews and a daily log ensures information is up to date and accurate. Care plans were individual in nature person centred and identified individual abilities and needs. A key worker system and an increase in staff hours mean that residents are now supported to achieve a wide range of goals with more choice, greater access and increased opportunities. Discussion with the management team and staff indicated that there was a good working knowledge of service users needs. Staff work in small teams with the same groups of service users and know their needs well. Discussion with two service users and observation of practice showed that residents felt positive about their care and confident that their needs would be met. During the inspection three service users remained at home others were attending at day centres and colleges. Those who remained did so out of choice and were supported by their key workers in a range of activities within the community. Service users were supported to prepare their own lunch undertake general domestic tasks for themselves and to undertake general gardening. One resident chose to go out for coffee the atmosphere was relaxed, informal and decisions made were service user led. Following a hospital admission the home have recently set about creating a “passport” for one service user which contains information about how best to communicate, likes and dislikes, mannerisms and preferences. It is the intention that a passport will be created for all service users and was considered by the inspector to be one example of very good practice. There was evidence that the home had sought advice from local advocacy services and had thought creatively about how residents are supported beyond the extension of the home. There were risk assessments in place for individual activities and evidence that residents are supported in a wide range of interests, day trips and more recently holidays. New risk assessments are generated when residents undertake previously untried and untested activities. In line with a recommendation made at the previous inspection out of date information on service users files has been archived in order to better identify which information currently applies to service user care. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service Additional staffing hours have meant that the home is able to offer a greater range of activities, which has given service users more flexibility and choice increasing their access to the local community. Service users maintain links with their families and friends and are encouraged to seek support and friendship in the wider community. Staff are committed to maintaining residents privacy and dignity and have worked hard to improve practices in the home so that residents can have more opportunities for personal development. This includes creating more opportunities for residents to plan and prepare their own meals. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 12 EVIDENCE: Greater staffing hours have meant that the home has been able to offer increased choice in daytime activities. One service user spoken to has been able to meet with a friend from college enjoys lengthy walks with his key worker and travelled to London for a trip on the London eye. A week’s residential course at a distance learning college had also been arranged for that resident and had been thoroughly appreciated. The home has arranged through the local authority for all residents to be provided with bus passes, which has further increased access. Where appropriate and with some assistance service users are able to venture beyond the local town making their way if necessary to keep medical appointments at an adjacent town. Individual activities enjoyed and recorded within the community are varied and person centred and are at times, which are flexible for residents. These include bowling, cinema going to the local pub seeing friends and family, day trips, short holidays, football matches attending college and other training courses. Activities and goals are as wide and varied as service users wish them to be and the philosophy within the home as described by the manager is one in which the staff team fully support this. Service users can receive visitors when and where they wish. Family and friends are welcomed and their involvement in activities is encouraged with the service users agreement. A relaxed and informal atmosphere within the home saw staff and residents interacting at a high level and comfortably with one another. Service users were observed to move freely around all the communal areas of the home and could choose whether to spend time in company or in the privacy of their bedrooms all of which had locks. Service users responsibilities for domestic tasks were clear and they have opportunities for taking part in doing their own laundry, cleaning, shopping and managing their own money with support from staff as identified on individual care plans. Observed examples during the inspection included service users going shopping, preparing their own lunch, washing clothes and laying the table for the evening meal. Residents were very well motivated and happy to be involved. Menu’s are planned in advance by catering staff and include a good choice of evening meals. Breakfasts are prepared independently by residents in their own kitchens and those who wish to be supported to prepare their own lunch. Produce is fresh with a range of fruit and vegetable. Residents are encouraged to make decisions about what they want to eat and where they choose to eat is flexible within their living areas. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service The home provides personal guidance and support according to assessed need and in line with resident’s preferences and wishes. Policies and procedures relating to the health care needs of service users promote good practice and ensure physical and emotional needs are met. Medication held at the home is well managed to ensure that service users medication needs are met and they are protected through the policies, procedures and practices within the home. EVIDENCE: Care plans clearly outline where guidance and support is needed for care and how this must be provided in line with service uses wishes. Residents are supported in deciding what they wish to wear, when they choose to go to bed and there was evidence on files examined of appropriate referrals to occupational therapists, psychiatry and psychological services. Continuity and consistency of support is given through a dedicated key worker system and in the case of one resident additional support was sought through advocacy Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 14 services. Care plans set out preferred routines, needs and preferences, likes and dislikes for residents who cannot easily communicate something which will be further strengthened through the creation of the resident “passport”. Staff members usually attend clinic and outpatient appointments with service users. There was evidence on file of good links with health care providers locally and residents have access to a range of healthcare facilities including dentists and chiropody. Up dated policies and procedures are in place regarding medication in line with a previous requirement and there is a suitable system of storage, administration and disposal. Medication records were accurate and matched the information on the MAR sheet. Senior staff has received relevant medication training. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service The home has a satisfactory complaints system in place with some evidence that service users are promoted to raise concerns and their views are listened to and acted on. Service users are safeguarded by staff’s knowledge of adult protection procedures and written policy. EVIDENCE: Resident meeting minutes seen evidenced that service users are given the opportunity in these meetings to raise concerns or complaints. In discussion with staff they were also clear about how to highlight whether a service user is unhappy and how to support service users in making complaints. An up to date adult protection policy is in place and staff spoken to felt able to raise any concerns with the management team. The complaints log is maintained and evidences that complaints are acted upon although it is noted that accounts of events could be more usefully detailed. The manager confirmed that staff have attended relevant training in adult protection and there is an up to date policy available. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service The home provides service users with a comfortable and homely environment, and continues to benefit from a programme of redecoration and replacement. The home was clean and hygienic with good procedures in place to protect service users from the spread of infection. EVIDENCE: A tour of the premises was carried out as part of the inspection. All communal areas of the home were viewed and a sample of service users bedrooms. The premises comprise of four different living units with between four and nine residents accommodated in each unit. Each unit has a small kitchen, dining room lounge and bathroom and all are made to look homely. Some of the kitchens are in need of updating and re-decoration. The home confirmed that plans are in place and that this is part of a rolling programme of maintenance. The home continues to offer a respite service despite the fact the management team and staff consider the permanent residents would prefer not to share Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 17 their accommodation with short term residents. The deputy manager confirmed that this facility had been substantially underused during the previous year and some consideration was being given to accommodating younger adults in transition from children’s services. A recommendation was made at previous inspections that the accommodation was made more suitable for a resident who uses a wheelchair. There are currently no wheelchair users at Alexandra road so this standard was not fully assessed on this occasion. The home was observed to be clean and hygienic. Laundry facilities are appropriately sited and suitable for the needs of service users. Good policy and guidance is available for staff on infection control. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is poor. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service Substantial increases to staffing levels within the home have made a considerable difference to service users quality of life promoting their choice and opportunities for personal development. Staff files for newly recruited staff demonstrate that the home operates proper recruitment procedures. However since 2004 it has been a requirement that all staff must receive enhanced CRB checks. The homes inability to evidence that continues to place service users at risk. The home demonstrates a commitment to providing a well-qualified staff team and the training programme has been expanded to include courses designed to give staff an understanding of some of the specialist needs of service users to ensure their needs can be met. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 19 EVIDENCE: Staffing hours at the home have been increased which means that the home is continuing to provide staffing in accordance with the hours recommended by the Department of Health’s calculation guidance. Rota’s were examined and this showed the extra hours were being used to provide additional staffing during the day to offer residents more choice of activities and promote their independence. Only one new staff member had been employed since the last inspection. The file contained all the relevant information and demonstrated that robust recruitment procedures are in place. However discussion with the Registered manager revealed that the home couldn’t confirm that enhanced Criminal record bureau checks are in place for all members of staff. The two previous inspections highlighted the need for this requirement to be met the home must now address this requirement as a matter of priority. The home demonstrates a commitment to providing a well-qualified staff team each staff member has an individual learning plan and staff confirm that they have access to regular training. A record is kept of all courses completed and training planned for the future demonstrates that staff undertakes courses linked to the specialist needs of residents such as autism, mental health issues, learning disabilities and managing complex needs. There are currently six care staff that have obtained NVQ 2 another six have almost completed. The home are well on the way to meeting this requirement demonstrating a commitment to ensuring staff are suitably qualified. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is poor. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The home benefits from an experienced manager and senior team whose roles and responsibilities are clearly defined, which ensures that all aspects of the home are well covered. The home encourages feedback about the quality of service from service users the lack of a formal quality assurance system however means that the home is not in a position to demonstrate that there is an on-going review of aims and outcomes for service users. The home generally follows practices that promote and safeguard the health, safety and welfare of service users. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager has extensive experience of providing services for people with learning disability and has managed Alexandra Road for a number of years. He holds the Certificate in Social Services and the Certificate in Personal Social Services management. There was evidence that he was keeping his knowledge and skills up to date and has recently completed training on autism and total communication. Management and staff do speak to and consult with service users about care provision and this was seen in records and minutes of residents meetings. There was also evidence that views are sought from service users on a twiceyearly basis through formal surveys. However this was not extended to friends and family or to staff and community health professionals. Results of surveys are not yet collated and included in the homes annual development plan. A carbon record of incidents and accidents is maintained although these are not clearly recorded or audited. Whilst accidents and falls do not appear to be a frequent occurrence the home does not provide sufficient evidence to demonstrate that there is monitoring of such occurrences. Where there had been an incident involving a service user this had not been notified to the commission. Records evidence that staff have undertaken relevant Health and Safety training and all servicing and maintenance of equipment was confirmed by the registered manager to be up to date. Inspection of the premises demonstrated that routine maintenance and refurbishment work was being implemented. Fire records demonstrated that staff had received regular training although it was not possible to ascertain from looking at the fire records content and duration of training. The home has comprehensive Health and Safety systems in place to ensure the safety and welfare of residents. Staff receive regular training in Moving and Handling, First Aid, food hygiene and infection control. Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 N/A 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 1 X X 2 x Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The registered provider needs to achieve the target of at least 50 of care staff achieving a NVQ 2 qualification in care. (Previous timescale of 01/10/05,01/06/06 almost met.) All staff must receive an enhanced CRB and POVA 1st check this must include all new and existing members of staff. The Registered manager must develop quality assurance methods based upon seeking the views of service users and other interested parties, to ensure success in achieving the aims and objectives of the home. An annual development plan must be produced reflecting the outcome of the consultation. (Previous timescales of 09/0309/05/-04/06 not met The registered manager must develop and implement a policy/procedure for the recording, investigation and audit of all accidents The registered manager must report to the commission all accidents, injuries, illnesses and DS0000032045.V297984.R01.S.doc Timescale for action 1. YA32 18 12/08/06 2. YA34 19 12/08/06 3. YA39 24 12/09/06 4. YA42 13 12/07/06 5. YA42 37 12/07/06 Alexandra Road (25/27a) Version 5.2 Page 24 6. YA42 13 communicable diseases or incidents that occur within the home and which affect the wellbeing or safety of any service user. The record of staff fire instruction must include the name of the instructor, the content and duration of the session. 12/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA14 Good Practice Recommendations Service users should be enabled to have a holiday outside of the home. (This recommendation was not inspected on this occasion and is brought forward from inspections dated January 2004 and January 06) It is recommended that the home’s short term care service is reviewed, as the communal areas cannot be separated from the living areas of the permanent residents and therefore, has a negative impact on the permanent residents in the home. (Bought forward from inspection dated Jan 06) 1. 2. YA24 Alexandra Road (25/27a) DS0000032045.V297984.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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