Inspection on 31/10/06 for Alex Wood House

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alex Wood House 24/10/08

Alex Wood House 25/10/05

Alex Wood House 26/04/05

Alex Wood House 24/10/04

Alex Wood House 08/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Alex Wood House 3a Fortescue Road Cambridge CB4 2JS Lead Inspector Janie Buchanan Key Unannounced Inspection 31st October 2006 09:00 X10015.doc Version 1.40 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 Alex Wood House DS0000015088.V317287.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 Older People. 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. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alex Wood House Address 3a Fortescue Road Cambridge CB4 2JS 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) 01223 578602 01223 578460 Cambridge Housing Society Ltd Ann Tait Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (3) of places Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age range of two residents in the Physical Disability (PD) category is 60 - 65 years only. This age range applies to short stay placements only. One named resident under the age of 60 years with physical disabilities 25th October 2005 Date of last inspection Brief Description of the Service: Alexwood House is owned and managed by Cambridge Housing Society, a charitable housing association. The home is situated to the north of Cambridge City and is about 2 miles from the city centre. There are shops, a post office and a library nearby at Arbury Court. Alexwood House was purpose built for older people in 1988 and offers mostly permanent care. There is also a busy day centre. It is a pleasant modern building, built around a central courtyard. All bedrooms ensuite facilities. Charges vary between £425 and £522 per week Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s key inspection for the year 2006/7. It was unannounced. The inspector interviewed four residents, one visiting relative, three members of staff and the manager. A brief tour of the home was undertaken and a range of documents was viewed. The inspector also received twenty-two comment cards requesting feedback about the home, completed by residents and their relatives. Most respondents were very pleased with the overall service provided at Alexwood House, although one resident felt the choice of food she could have as a diabetic was limited and another resident was disappointed they could not get access to digital television. What the service does well: 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 Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 6 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is good. Information is available about the home to help prospective residents choose if it is where they want to live. EVIDENCE: The home has an information pack for prospective residents. This pack is comprehensive and includes the home’s statement of purpose, its aims and objectives, its complaints procedure, a residents’ satisfaction questionnaire, photographs and information about daily life in the home. All residents who completed the questionnaire responded that they had received enough information about the home before moving in. Senior staff carry out pre-admission assessments for all prospective residents and there were copies of this assessment on the files viewed. All residents are issued with a ‘Licence to Occupy Residential Accommodation’ which clearly states the terms and conditions of their stay at the home Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. Residents receive health and personal care based upon their needs and they are involved in planning their care. Residents’ privacy is respected. EVIDENCE: All residents who completed the questionnaire stated that they received the care and support they needed, in a way that they liked. Residents are actively encouraged to be involved in their care planning and reviews and one resident had completed parts of her care plan herself. The plans viewed were detailed and paid particular attention to residents’ past social history. Health care needs were clearly noted, and residents’ dependency profiles, nutrition and weights were monitored closely. Risk assessments had been completed in relation to residents’ falls, and their moving and handling needs. Daily notes were generally detailed and legible, although sometimes the language used in them was inappropriate and patronising. For example one resident was described as ‘well behaved today’. The manager is aware of this issue and currently addressing it. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 10 Medication storage and records of administration were checked and found to be adequate, although there was a minor recording discrepancy found in relation to one of the controlled drugs. Dates for when some bottles of liquid medication had been opened had not been noted, and dates in the controlled drug register had not been recorded fully. A recent (20/09/06) inspection from the supplying pharmacy found the medicines to be generally well organised, with ordering under control and the MAR sheets used well. Residents spoken to confirmed that staff were courteous, respectful and communicated well (despite some strong accents from overseas staff). One resident commented; ‘my privacy is never invaded, they [staff] always knock and are very polite’. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Quality in this outcome area is excellent. Residents enjoy a full and stimulating lifestyle. EVIDENCE: Activities are afforded a high profile, with something happening everyday at the home. On the morning of the inspection itself 15 residents were enjoying a musical quiz, facilitated by a skilled member of staff who worked hard at including all participants. A Halloween entertainment was planned for that afternoon. In addition to this, there had been a number of trips out to Ely cathedral, Tescos, Hunstanton and Sandringham. Forthcoming trips to a tea dance, a garden centre and shopping were widely advertised throughout the home. Many positive comments about these activities were received from residents and their families including: ‘the home makes every effort to do a good job and organises lots of activities’;’ plenty of mentally stimulating activities and trips provided’; ‘I really enjoy the quizzes, I like something that makes me think’. Visitors are made to feel welcome in the home and some were involved in the morning’s quiz. One visitor told the inspector: ‘They always offer me a cup of tea when I visit’. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 12 The winter menu was viewed and showed that residents have a choice of what to eat. The menu is a regular topic at residents’ meetings. All residents who completed the questionnaire stated that they either ‘always’ or ‘usually’ liked the meals provided at the home, except one who felt that diabetic meals were limited. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Residents are aware of how to complain and feel confident to do so. EVIDENCE: Cambridge Housing Society has its own, comprehensive, complaints policy that has been viewed on previous visits. Details of how to complain are also included in the home’s information pack and in the entrance to the home. Respondents to the questionnaire stated that they knew how to make a complaint, and those spoken to during the inspection were confident that their concerns would be taken seriously. Two residents told the inspector that the residents’ meetings were a good forum to raise their concerns The home has a suitable policy and procedure (November 2004) in place for dealing with the abuse of vulnerable adults, and staff receive training in this matter. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,26 Quality in this outcome area is good. Residents live in a comfortable and wellmaintained home with a range of indoor and outdoor space available to them. EVIDENCE: The home is purpose built for older people and has a variety of aids to assist residents such as hoists, bath chairs and grab rails. All bedrooms meet minimum size requirements and furnishings and fittings are of good quality. However, one bedroom viewed had unsightly small holes in the wall and another bedroom smelled strongly of urine. The manager was aware of this smell and staff have been working hard to try and eradicate it. Residents have an en-suite toilet and wash hand basin in their bedrooms. In addition to this there are six communal bathrooms with toilets. These are clearly marked and in close proximity to sitting rooms. An additional shower room is being created to meet the needs of residents. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 15 There is additional communal space available and an attractive courtyard garden for residents to enjoy the fresh air and sun. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Staff are trained, skilled and in sufficient numbers to provide a good service. EVIDENCE: The reliance on agency staff to cover vacant shifts has reduced considerably and a number of new permanent staff have been recruited. Residents reported that staff were available when they needed them, and that they never waited too long for help. Many positive comments were received about the staff form residents and their relatives including; ‘we have been impressed by the friendliness and courtesy of the staff, and their concern to make residents comfortable and happy’; ‘ I have nothing but praise for the staff at Alexwood house’; ‘they are very reliable and always listen when they are not busy’; ‘I am very happy and comfortable and I get on with staff very much, all of them’ It was not possible to check staff personnel files during the inspection as Cambridge Housing Society holds these centrally, however staff confirmed that their recruitment had been thorough, and all necessary references and checks had been undertaken before they started work at the home. Staff training is good and nearly 50 of staff have an NVQ level 2 in care. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,38 Quality in this outcome area is excellent. Residents benefit from a well managed home and from staff who feel supported and valued. EVIDENCE: There is strong evidence that the ethos of the home is open and inclusive with the views of residents listened to and valued. Minutes of residents’ meetings showed that they were actively consulted about the food, the garden area and activities. The manager is currently developing further methods to capture the views of residents about the service they receive. All staff receive regular supervision and felt that they were given clear leadership and good support from their management team. During the inspection the fire alarm went off, and staff responded quickly and appropriately to it. However, a number of large stones were viewed holding Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 18 back fire doors, thereby preventing doors from closing fully in the event of a fire. This puts residents at unnecessary risk. No other health and safety hazards were viewed during the inspection. Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 x x x x 2 Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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. 1. Standard OP38 Regulation 23(4)(a) Requirement The registered person must take adequate precaution against the risk of fire. Fire doors must not be pinned open. Timescale for action 31/10/06 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 Good Practice Recommendations Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. Extracts may not be used or reproduced without the express permission of CSCI Alex Wood House DS0000015088.V317287.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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