Inspection on 15/12/05 for Alexander Care Centre

This inspection was carried out on 15th December 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexander Care Centre 28/04/09

Alexander Care Centre 29/04/08

Alexander Care Centre 01/05/07

Alexander Care Centre 08/06/06

Alexander Care Centre 19/08/05

Alexander Care Centre 14/09/04

Alexander Care Centre 05/02/04

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

CARE HOMES FOR OLDER PEOPLE Alexander Care Centre 21 Rushey Mead Lewisham London SE4 1JJ Lead Inspector Sean Healy Unannounced Inspection 15th December 2005 09:45 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 Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 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. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alexander Care Centre Address 21 Rushey Mead Lewisham London SE4 1JJ 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) 020 8314 5600 020 8690 6100 Southern Cross Healthcare Services Limited Haiqin Li Care Home 78 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0) Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 20 patients, frail, elderly persons aged 60 years and above (female) and 65 years and above (male) 28 residents, elderly persons and persons aged 55 years and above with physical dependency 19th August 2005 Date of last inspection Brief Description of the Service: The Alexander Care Centre is a purpose built care home for Older People and was first registered in 1996. It was purchased by Southern Cross Healthcare Services Ltd in 1998, who continue to be the current registered providers. It is a spacious, bright and airy modern building, divided into three service user care groups. These comprise of people with dementia, residential care needs, and a nursing care needs. Service users who require nursing care are provided for on a separate floor. The home offers care to a maximum of 78 older people. There are 68 single rooms and five shared rooms, each with en-suite facilities. It is the stated objective of the home to provide individualised support and care services for people, in a safe comfortable and caring environment, meeting cultural psychological spiritual emotional and social needs. The Alexander Care Centre is situated in its own grounds in a cul-de-sac within a residential estate. It is close to local shops and public transport, with Lewisham Hospital being a 15-minute walk away. Public transport includes mainline rail services to central London (a journey of about 30 minutes) and buses and train services to the south east of London. There is ample free car parking space on site to facilitate service users and visitors. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out in one day on the 15/12/05. The registered manager was present and took part in the inspection process. The registered manager provided complete co-operation during the inspection. Information regarding the quality of care was provided by service users and a number of relatives of service users, who were visiting on the day. A number of social workers also provided background information on the quality of care, and provided their views on the progress and changes made by the home to improve services. The inspector interviewed one senior nurse, the home’s chef and one catering staff member, and spoke individually with a group of 6 service users over lunch. The inspector met individually with two other service users. Comments from all are included in this report. The inspection included a tour of the home, including the kitchen and laundry areas, and examination of records on care plans, staff records and building maintenance records. During the inspection, staff interaction with service users was observed to be very regular and conducted in a respectful manner. What the service does well: What has improved since the last inspection? The home’s system for assessing and planning for service users’ social and leisure care needs has been revised and is now very comprehensive. The system for carrying out risk assessments has also been revised to improve the way staff are instructed on how to manage risk for service users especially in Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 6 the area of moving and handling. Some work needs to take place to complete these for all service users (refer to “What they could do better section). The home has now introduced a system for recording progress in implementing care and support activities, which will benefit service users when it is fully up and running. The community pharmacist has now visited the home and passed the home medication management system as adequate, making a few recommendations. (Refer to “What they could do better” section). An outstanding complaint has now been resolved and the home has introduced a good system for keeping track of complaints which will ensure that complaints are dealt with effectively and quickly. The home’s manager has agreed a system for informing service users about the homes business plan and involving them in developing the new business plan. There is a meeting planned in January 2006 to do this. 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. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 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 Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 6 Current and prospective service users have adequate information provided in the home’s Statement of Purpose and Service User Guide, to enable informed choice about where they live. Though all service users at the home have needs assessments, these do not yet fully include Social and Leisure needs, which prevent the home from adequately meeting these needs. The home ensures that the means and strategies for ensuring that assessed needs are met are based on current good practice. EVIDENCE: The home’s Statement of Purpose and Service User guide were revised in June 2005, and clearly state the services and accommodation, which are to be provided. The staff and service users were involved in this review, through staff and service user meetings. One family member stated that they had been asked about their views on this review and thought that the home provided well for their relatives needs. Two service users confirmed that they were spoken to also. The manager said she is aware of the need to fully include service users in future reviews of the Statement of purpose and Service User Guide and will do this in future reviews. The previous recommendation is now met. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 9 A lot of work has now been done on changing the homes own system for assessing service users care and support needs to include social and leisure care needs. These look very good and comprehensive and have been completed for a number of service users. These assessments need to be completed for all service users. (Refer to Continuing Requirement OP3 partially met, still within timescale deadline) The home gets input from the Community Health Support Team to help with information, training and ideas for improving the care of service users with dementia and cognitive impairment support needs. Needs of service users from ethnic communities are reflected more now in the homes appearance practices, and the home has pictures reflecting service users backgrounds and personal taste. One service user’s relative said that his mother’s needs have increased and the home looks after her very well. He said, “She is very happy here”. The family of one service user who visits weekly said that “ A Number of staff are difficult to understand because English is not their first language, but this is improving and they are very caring of my mother”. Many of the staff whose first language is not English have been improving communications by attending formal English classes by agreement with the homes management, a practice which is to be commended and which many have stated has improved communications between staff, service users and families. The home has now also included diversity training in the staff training schedule to raise awareness of cultural issues and aid development of strategies for ensuring that service users needs are fully understood. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Service users’ health care needs are set out in an individual care plans, and social and leisure care needs have begun to be included. This process needs to be fully implemented to ensure that there is improvement to service users quality of life. Service users health care needs are fully met and they are protected by the home’s policy and procedures for dealing with medicines. Service users feel that they are treated with respect, and that their right to privacy is fully upheld. EVIDENCE: Service users plans are based on needs assessments carried out by the home or by the referring agency. Plans regarding 6 service users reflected good detail regarding health, diet specific, specialist feeding support requirements, respiratory support needs, and emotional behavioural needs, and how these are to be met. A previous recommendation to reflect life histories of individual service users in the planning system is now being implemented and the manager was able to show that she had begun a process for compiling this information, in that there is now formatted paperwork in place. The staff and manager have now begun the process of seeking information from the services users and relatives/friends, which will be reflected in planning in the form of social and leisure activities and reminiscence. This work has been completed Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 11 for a number of service users and must be completed for all service users in consultation with them or their representatives. Discussion with some relatives showed that they had been asked for information and were aware of this work happening. (Refer to Continuing Requirement OP7 partially met) The risk assessment system has now been revised and improved to include better instruction for staff in how to manage risk such as that involved in moving and handling when service users can’t fully independently walk. Risk assessments are in place for all service users and are produced in a new standard format showing the risk with a brief statement attached to each risk as to how it is to be managed. Health Care support is excellent and the homes management promotes involvement from external professionals and family with daily involvement from a visiting GP, and weekly visits from other health professionals such as community nurse, tissue viability nurse, continence advisor. The home also has support from a very skilled community health support team who provide advice and some training for staff. GPs are contracted to visit the home a number of times each week, and the PCT nurse and community nurse visit a few times a week. Other professionals such as dentist, dietician and tissue viability nurse are also fully involved. Care plans for health needs are very comprehensive and are reviewed at least monthly. The home has a policy on Medication and has adequate systems in place for safe storage and administration. At last inspection the home was asked to ensure that the pharmacist report on her findings from a visit in August 2005, which is currently overdue, is made available at the home and any recommendations be actioned. The registered manager tried to get a copy of this report but this proved impossible and the manager requested another visit, which happened in December 2005. A copy of a brief report was available at the home showing the following recommendations: 1. Order PRN medication at least 3 days before the current supply runs out 2. Include clinical dressings and PRN medication on the medication sheets 3. Dispose of sharps (old needles) at least monthly 4. Get spare keys for clinical room where medication is stored The home needs to act on these findings. (Refer to Requirements OP9) Service users and some relatives interviewed commented that the staff and management are very respectful and rooms are very comfortable and are private. Sixty-eight out of seventy three rooms are private and the double rooms are large with separating screens provided. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 14 The home does not yet fully ensure that service users’ lifestyle in the home matches their Social, Cultural and recreational interests, without which their quality of life is seriously impacted upon. Service users are supported to maintain contact with family friends and others of their choosing, and are helped to exercise choice and control over their lives. EVIDENCE: Service users assessments and plans are not complete in relation to specific information about their social background, leisure interests, hobbies and desired activities. (Refer to standard 7 for comments and requirements) This prevents the home from adequately knowing what individual service users needs are in this area and meeting them. However the manager has begun work to improve this situation in starting the process of compiling information for each service user (Refer to standard 7), and in appointing a dedicated activities co-ordinator. There has been good progress in putting in place a better assessment a planning tool to provide better for social and leisure care which should also improve opportunities for local community activity. (Refer to Continuing Requirement OP12 partially met) The home has a visitor’s policy, which is understood by service users and their relatives, which does not place restrictions on visiting hours. The homes Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 13 manager has compiled information on local places to stay for families who may wish to stay overnight nearer to their relative. The home promotes independence for service users and involves families and friends and the local authority in advocating for service users needs when it is appropriate. Service users religious needs are well catered for. The home has excellent systems in place for protection of service users personal finances. The homes assessment system includes service users abilities and needs regarding managing personal finances and benefits. Generally service users or their families take responsibility for all financial affairs and ask the home to look after small amounts of money on behalf of service users, usually £30 to £40 pounds for personal spending. Where this happens it is fully agreed in writing and excellent records are being maintained to protect service users interests. Three service users have asked the home to help them manage their finances held at their banks. These accounts are in service users names and again all transactions are fully documented and maintained on the homes computer system. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The homes records now demonstrate that service users’ and their representatives’ complaints are listened to and fully acted upon. EVIDENCE: The home has a complaints policy, which meets requirements, and which is understood by staff interviewed. Service users said they know how to complain and that they would speak with the manager if they were worried. A service user’s relative said that they had been informed how to make a complaint, and said they that the manager is approachable and listens and is in the home on a daily basis. There have been two complaints since last inspection one of which was substantiated, and one was not upheld. An outstanding complaint has now been resolved. The home has introduced a good system for keeping track of complaints, which will ensure that complaints are dealt with effectively and quickly. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users have the specialist equipment they need to maximise their independence. EVIDENCE: The home is modern, and well equipped with the equipment needed by service users to meet their assessed needs. Grab-rails, hoists and a range of aids such a wheelchairs and walking frames are in use specific to assessed needs. The home has a modern well-maintained lift between floors. Two new standing hoists and one whole body hoist are available to help with moving and handling and to minimise risk to service users and staff. There is an alarm call system for service users to call for help at night. This system is supported by the staff logging each call describing the action taken, which is reviewed by the manager daily on a computerised printout system. Staff remind service users nightly how to use the alarm call bell. A concern was raised about the condition of a wheelchair and hoist in one service users bedroom. The wheelchair was provided by the service user, when she was recently admitted, not by the home, and was in a poor state of Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 16 repair. The manager said she had unsuccessfully tried to get funding for a new chair from the health service, and had now agreed for the home to buy a new chair. This is currently awaiting a formal assessment. The hoist was in need of cleaning and the manager agreed that this would be done as soon as possible. It was felt that the home was taking all appropriate action to resolve this situation. It is recommended that the homes system for carrying out checks on the state of repair and upkeep of such equipment be reviewed to ensure that cleaning and repairs are identified quickly and addressed. (Refer to Recommendations OP22) Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Service users’ needs are met by the numbers and skill mix of staff, and they are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices and the home’s staff are experienced, trained and competent to provide for the assessed needs of service users. EVIDENCE: Seventy-eight service users are supported by a staff team consisting of one registered manager, three senior staff who supervise staff, nine qualified nursing staff and fifty-three care staff. The home is divided into three separate types of care as follows; 1. Nursing care needs 2. EMI Unit 3. Residential care. The nursing care unit is staffed by one nurse and three carers during the daytime and one nurse and two care staff at night. The EMI Unit is staffed by one nurse and five carers during the daytime and one nurse and two carers at night. The Residential unit is staffed by one senior carer and four other carers in the daytime and one senior and two carers at night. The manager expressed that these staffing levels are adequate and no concerns to the contrary have been raised. There is no use of agency staff currently. There is a training and development programme for staff, which the manager maintains on a computer spreadsheet, which is detailed and enables her to update staff training. A copy of the programme from April 2005 is available, and this included training on dementia, fire safety, moving & handling, food hygiene, health and safety, medication, adult protection, and other relevant Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 18 courses. Diversity training is also included and the home has provided a weekly English language-speaking course for any staff who need it. Some staff commented that they are happy that this is available and a number of service users and relatives said that communications has improved. 22 care staff have achieved NVQ level 2 training at Lewisham College, which meets requirements regarding NVQ training. A number of other staff are on the NVQ course also. The home uses a formal induction schedule, which meets TOPPS induction standards. The home has engaged the Community Health Support Team in advising and training regarding care of the elderly and dementia awareness training and staff commented that this has been helpful in improving their understanding. All support staff recently attended a one-day “work in care induction framework” workshop, as a refresher course, and staff commented very positively about this training. Six staff files evidenced that the above training was in place. Examination of seven staff files showed that great care is being given to maintain high standards in the homes recruitment practices and excellent records are being maintained in all areas regarding staff recruitment, health checks, reference checks, qualifications and training. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Service users live in a home which is being run and managed by a person who is fit to be in charge and who is of good character and able to fully carry out her responsibilities. The home’s quality assurance systems do not yet demonstrate that the decisions are made in full consultation with service users, which may result in their exclusion from important decision-making. Service users’ financial interests are well safeguarded. Staff are not being appropriately supervised, which may affect their ability to do their jobs. Service users’ and staff health, safety and welfare are being promoted and protected. EVIDENCE: The present registered manager is a registered nurse and does have a management qualification at NVQ level 4 in care and management. The manager is supported by three senior nursing and care staff, who help supervise care staff. There have been a lot of positive improvements in the management of the home in the past twelve months and this has been Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 20 reflected in comments from service users and families, and in comments received from health care professionals attending the home. The home makes efforts to consult with service users and families through having three-month relatives meetings, a Tuesday morning “consultation surgery” and has now developed a system for carrying out service user satisfaction surveys, which has not yet been implemented. Currently findings from the above systems and action taken are not being formulated into a quality assurance report. The home must develop a system for conducting an annual audit which involves service users and their families and ensure that the results of this audit and service user satisfaction surveys are published and made available to current and prospective service users. (Refer to Repeated Requirement OP33) The home has very good systems in place for the protection of service users money and valuables, which protect their financial interests. (Refer to comments under Standard 14 of this report) There is some confusion among service users as to whether they are invited to relatives meetings. A number of service users said they do not go to meetings for service users as they are not sure when they are happening. It is recommended that the home’s manager clarify this subject with all service users and ensure all service users are invited to such meetings and asked for their views on matters effecting them. (Refer to Recommendations OP33) The manager is present at the home on a daily basis and does provide constant informal supervision for staff. The three senior staff together with the manager provide formal supervision. However records and comments from the staff and manager show that formal supervision is not happening at least every three months and this must be rectified. (Refer to Requirements OP36) Discussion with senior staff also identify a need for senior staff to receive some update training in staff supervision methods. (Refer to Recommendations OP36) The home provides very satisfactory systems for management of health and all safety matters. Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 21 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 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X 3 X X X X 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 X 2 X 4 2 X 3 Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes but still within agreed timescale 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 OP3 Regulation 14 (1)(c) Requirement The registered manager must ensure that all service users needs assessments also include details of social interests, hobbies, religious and cultural needs. This is a repeat of a previous requirement, partially met still within agreed Timescale of 28/02/06. The registered manager must ensure that all service user plans include details of how social care needs are to be met and reviewed. This is a repeat of a previous requirement, partially met still within agreed Timescale of 28/02/06. The registered manager must ensure that social and leisure activities are developed in full consultation with service users and reflect their assessed needs. This is a repeat of a previous requirement, partially met still within agreed Timescale of 28/02/06. The registered provider and DS0000007002.V268805.R01.S.doc Timescale for action 28/02/06 2. OP7 15 (2)(c,d) 28/02/06 3. OP12 16(2) (m,n) 28/02/06 4. OP33 24 (1,2,3) 28/02/06 Page 23 Alexander Care Centre Version 5.0 5 OP36 18.2 manager must develop a system for conducting an annual audit which involves service users and their families and ensure that the results of this audit and service user satisfaction surveys are published and made available to current and prospective service users. This is a repeat of a previous requirement, partially met still within agreed Timescale of 28/02/06. The registered manager must 28/02/06 ensure that all staff receive formal supervision as often as is required but at least every two months RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered manager should address the good practice recommendations outlined within the Pharmacists report of December 2005 to ensure the safe management of service users medication The registered manager should ensure that the service users wheelchair discussed in this report is replaced, and the hoist referred to is cleaned The registered manager should review the system for checking on the repair and upkeep of wheelchairs and lifting equipment to ensure that checks are done at least weekly and appropriate action is taken The registered manager should ensure that all service users are made aware of planned service users meetings and clarify to them that they are also invited to relatives meetings The registered manager should explore supervision and other management training needs with senior care staff and provide any training identified to ensure effective staff DS0000007002.V268805.R01.S.doc Version 5.0 Page 24 2 3 OP22 OP22 4 OP33 5 OP36 Alexander Care Centre supervision Alexander Care Centre DS0000007002.V268805.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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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