Inspection on 19/08/05 for Alexander Care Centre

This inspection was carried out on 19th August 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 15/12/05

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 Alexander Care Centre 21 Rushey Mead Lewisham London SE4 1JJ Lead Inspector Sean Healy Unannounced Inspection 19th August 2005 10:00 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 Alexander Care Centre DS0000007002.V250060.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.V250060.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alexander Care Centre Address Alexander Care Centre 21 Rushey Mead Lewisham London SE4 1JJ 020 8314 5600 020 8690 6100 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) 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.V250060.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 16th December 2004 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.V250060.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 19th July 2005. 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 visiting GP and 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 two staff individually and met informally with a group of 6 service users over lunch. The inspector met individually with two service users. Comments from all are included in this report. The inspection included a tour of the home 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, despite being very busy day. What the service does well: What has improved since the last inspection? Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 6 Some work has been done on risk assessments to make people safer. The home has now looked at some problems with medication and has a pharmacist involved who has given advice on the best times to give medication. Senior staff have now been trained in how to help older people who are very ill and all of the other staff are also going on this training. An activities coordinator has been employed to improve leisure and social activities offered to service users and staff are to get further training in how to provide activities suitable for older people. There is now a separate room where service users can meet with their visitors apart from their bedrooms. Service users and relatives spoken to said they understand that relatives can visit the home at any time. This is now written in to the homes visitor’s policy. Cultural needs are now catered for in how the homes menus are decided on, and one service user said that curried lamb and ravioli are now on the menu, which they enjoy. The manager has now had an assessment carried out which shows the reasons why individual service users need bedrails and people who use them have agreed in writing that they need them on their beds for their safety. The home has changed the way people are placed around the home and now people who need specialised care and high support are situated so that they can most easily access trained staff. The alarm bell for service users to call staff is explained to service users each night to ensure they remember to use it if needed and the system provides the manager with written information as to why it was used and what staff did to help. A continence advisor is now helping the home to make sure that service users who need this support are not made uncomfortable or hurt and the GP said there is good control of this problem now. A team manager has now been recruited and has been appointed by CSCI as registered Care Manager. The manager has ensured that there are full assessments on file about service users finances and that there is a formal agreement when service users need the home to look after their money. What they could do better: Service users assessments need to be improved in the area of social care needs to help the staff to know what people as individuals like to do and talk about. Risk assessments need to be better at informing staff as to what individual service users support needs are, not just describing the risk in a Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 7 general way. For example when a service user needs two staff to help them to move the risk assessment should say if that person has any particular needs such as a weakness on one side which they should be careful of. The newly appointed activities co-ordinator needs to get to know peoples social and leisure needs better and involve service users in deciding on group activities when drawing up schedules. The manager needs to become more aware of how the cook makes sure that service users with special food requirements are catered for. The manager needs to put in place a better system for keeping track of complaints, and make sure that people who complain always get a letter telling them what has been decided and what will be done in good time. 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.V250060.R01.S.doc Version 5.0 Page 8 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.V250060.R01.S.doc Version 5.0 Page 9 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, 2,3,and 4 Current and prospective service users have adequate information provided in the homes Statement of Purpose and Service User Guide, to enable informed choice about where they live. Excellent written contracts are in place to ensure that service users have agreed the terms and conditions for living in the home. Though all service users at the home have needs assessments, these do not 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 homes 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. However there needs to be a more all encompassing system for conducting such reviews to provide a greater number of service users with the opportunity to be involved. (Refer to Recommendations) Staff time has now been allocated to ensure that the Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 10 Service User Guide has been explained to service users and an information sheet is attached to the front of each service users file. Excellent detailed contracts are in place for each service user, which fully explain contractual terms and conditions, and copies are provided to privately funded service users, and to service users funded by local authority contracts alike. Specialist services and services which will incur additional costs are specified. Services include chiropody, opticians, dentistry, hairdressing, aromatherapy and private shopping. Terms under which contracts will end are also described. Six service users assessments were examined and these showed good attention to health and clinical care needs, but were largely absent in information regarding Social care needs and preferred leisure activities. It was agreed that Social histories are very important to assisting staff to know service users to facilitate informal reminiscence and in developing the home’s activities routines with service users. (Refer to Requirements) The home has now started to get 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 now has pictures reflecting service users backgrounds and personal taste. One service user said that staff asked me about what pictures I want on my wall and my room is the way I like it. The family of one service user who visit weekly said that “ I know many staff are from abroad but they are very caring and hard working and offer my mum activities which she used to like, but which she now regularly refuses” 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. Given the diversity of ethnic backgrounds within the home it would be beneficial to all if the home provided more specific training in managing this diversity. (Refer to Recommendations) Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 11 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): 7,9, and 11 Service users’ health care needs are set out in an individual care plan but Social care needs are not included without which there is a serious impact on service users quality of life. Service users are protected by the homes policy and procedures for dealing with medicines. The home tries to ensure that service users and their families are treated with care, sensitivity and respect in the event of illness or death. 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 has not been met but 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 now need to begin the process of seeking information from the services users and relatives/friends, which should then be reflected in planning in the form of activities and reminiscence. This should also include consideration for service users to be supported to have outings to places of interest to them. (Refer to Recommendations) Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 12 Risk assessments are in place for all service users and are produced in a standard format showing the risk with a brief statement attached to each risk as to how it is to be managed. Risk assessments need to be better at informing staff as to what individual service users support needs are, not just describing the risk in a general way. For example when a service user needs two staff to help them to move the risk assessment should say if that person has any particular needs such as a weakness on one side which they should be careful of. Risk assessments need to be supported by more detailed brief instructions for staff describing the do’s and don’ts of how to provide support for the more critical risks such as moving and handling, self injury and challenging behaviour. (Refer to Requirements) The home has a policy on Medication and has adequate systems in place for safe storage and administration. The home was asked to ensure that they ensure that medication is given at correct times in consultation with a Pharmacy Advisor. The home has now done this and discussed and agreed on a specific issue regarding administration of medication prior to shift changes in the evening. The pharmacist is in the process of producing a report on her findings, which is currently overdue. The registered manager must get a copy of this report and act on its findings (Refer to Requirements) The home was previously required to ensure that staff receive training in dealing with death and dying. All nursing staff and eight senior support staff have now attended this training. Other staff are scheduled to attend in the coming months. It is to be recommended that the homes manager check that all of the service users have an agreement in place on file, describing their wishes in the event of serious illness or death, or where service users want family or friends to make such arrangements, a specific statement as to who they wish to deal with this matter including contact details. (Refer to Recommendations) Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 13 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 15 The home does not yet fully ensure that service users lifestyle in the home matches their in relation to 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 to enjoy wholesome meals of their choice. 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. The activities co-ordinator described his intentions for improving on activities and has begun producing weekly leisure activity routines. Five staff have now attended reminiscence communication and interaction training as required by the last inspection, and other staff are scheduled for this training. One relative of a service user said that his mother is now being offered activities regularly but “sometimes these are not activities she has been used to doing and so has not yet taken a great interest” The manager and activities co-ordinator need to ensure that there is a programme of social and leisure activities on offer to service users which reflects their Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 14 individual and collective needs, developed in consultation with service users (Refer to Requirements) The home has a visitor’s policy, which is understood by service users and their relatives, which does not place restrictions on visiting hours. In response to a previous requirement the home now has a separate “quiet lounger” room, in which service users can meet privately with relatives or friends. Two service users said that their family could visit any time they liked and that staff are friendly towards them and let them meet in private. The home operates seasonal menus, which are based on service users individual stated food preferences. Choices are checked at least weekly with service users by the homes chef, and service users are allowed to ask for specific meals on each day when they choose to. Special dietary requirements such as diabetes are assessed and a list of special needs is kept by the chef to ensure that these needs are not overlooked. Menus include curried lamb, ravioli, fish and chips and a variety of meat and vegetarian dishes. Six service users spoken to said that the food is good and they get to eat things they like to. One service user said “I love fish and chips and I have it twice a week” Another who was diabetic asked for a specific alternative dessert which was not strictly suited to his diabetes, but which after discussion he was allowed to have at his insistence. Staff demonstrated a good awareness of his needs but responded supportively to his request. Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 15 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 and 18 The homes records do not demonstrate that service users or their representatives complaints are fully acted upon. The home now demonstrates that reasonable measures are taken to protect service users from abuse. EVIDENCE: The home has a complaints policy, which meets requirements, and which is understood by staff interviewed. Two service users said they know how to complain and that they would speak with the manager if they were worried. A service users relative said that they had read the homes service user guide, which explained how to make a complaint, and they said that the manager is approachable and listens. However there have been seven complaints since last inspection one of which was substantiated and one of which is still outstanding though the complaint was made in February 2005. This complaint was regarding increase in fees and was investigated by a finance officer in the provider company. Though this complaint was finally brought to a conclusion in June 2005 the outcome letter did mot state whether the complaint was upheld, whether the service user was properly funded to pay the increase or whether they were now required to pay the increase. The registered manager and registered provider must ensure that the outcome to this complaint is properly clarified to the complainant and copied to CSCI. The registered manager must also ensure that a detailed register of complaints is maintained, which enables her to track complaints and ensure that all complaints are resolved within the timescale stated in the homes complaints policy. (Refer to Requirements) The home has an Adult protection policy in place, which reflects the local authorities policy. (Currently under review) There have been two adult Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 16 protection issues reported in the past twelve months, both of which are recorded as complaints. One of these already discussed was regarding fee increases, and the other was made by a relative of a service user regarding perceived poor response from staff when asking to make a complaint, and staff not following agreed care plans. This was investigated by social services and there were shortcomings in the homes practices identified. Appropriate action was taken by the provider and manager, who was since appointed as registered care manager. Comments from the homes visiting GP, and the social worker involved reflect a good response to dealing with these issues, a revision of care plans, and training for staff has resulted in substantial improvements in the quality of care provided. A requirement that the registered person must ensure that an audit is undertaken to ensure that bedrails are only being used to ensure service user safety has now been addressed, and all use of bedrails has been agreed in writing by the service users involved or an independent representative. Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 17 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): 19,22, and 26 The service users live in a safe well-maintained environment, which includes specialist equipment to maximise independence. The home is clean pleasant and hygienic throughout. EVIDENCE: The location of the home and its size and layout are well suited to the homes stated purpose and service user needs. It is a modern fully accessible home comprising of good car parking, secure entry facilities with an entry-phone, large clean en-suite rooms with adapted bathrooms available. The requirement to ensure that the EMI unit of the home is situated on one floor has now been accomplished, ensuring service users who need it have easy access to skilled nursing staff. A maintenance man is now employed full time to facilitate garden maintenance. Service user and visiting families commented that they were very happy with the homes facilities. Service users have access to all communal areas and to their bedrooms at all times of the day and night. Grab-rails, hoists and a range of aids such a wheelchairs and walking frames are in use specific to assessed needs. The Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 18 home has a modern well-maintained lift between floors. Two new standing hoists and one whole body hoist have been recently purchased. There is an alarm call system for service users to call for help at night. This system is now 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. Two service users said they were told about this system and knew how to use it. The home has good facilities in place for cleaning, laundering and disposal of clinical waste. A full time maintenance man deals promptly with repairs and all washing machines have a sluicing facility. The home was very clean and smelled fresh and free of unwanted odours. There was evidence that the home had now engaged involvement of a continence advisor and tissue viability advisor, and that all EMI unit service users had now been assessed re continence support needs. Service users stated that staff are sensitive when providing support and advice. Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 19 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): 30 The homes staff are experienced, trained and competent to provide for the assessed needs of service users. EVIDENCE: 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 was provided to the inspector, and this included training on dementia, fire safety, moving & handling, food hygiene, health and safety, medication, adult protection, and other relevant courses. 29 staff are on NVQ level 2 training at Lewisham College, which meets requirements regarding NVQ training. 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. Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 20 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): 32,33 and 35 The service users now benefit from a stronger leadership and management approach and a clearer understanding of the ethos and value base for care provision. The homes quality assurance systems do not yet demonstrate that the decisions are made in full consultation with service users. Adequate measures are in place to ensure that service users financial interests are safeguarded. EVIDENCE: The home and service users now benefit from the appointment of a registered care manager, appointed in June 2005. Discussion with some families a number of service users, a GP and a social worker reflect increased confidence in the homes management. Comments include “ she listens and is very good and kind” “Communications and medical practices have improved greatly” “ I trust the manager and would speak with her if I had a problem” There has been a positive response to dealing with problems and a commitment to making improvements in line with inspection requirements. There has also Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 21 been a recognition of some of the main problems such as a need to improve communications created by language barriers and a positive approach to encouraging and supporting staff to improve communications and general standards of care and support. One area which needs stronger definition for staff is the in understanding the homes ethos to involve service users and to identify and support social care needs. This has been discussed in a separate section of this report (Refer to standard 7) The home needs to do more to raise staff awareness regarding its values base (Refer to Recommendations) 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 requirements) The home still needs to consider how it will involve service users in the development of its business plan. (Refer to recommendations) Service users and families interviewed could not describe having been involved in service user surveys or any awareness of the systems for consultation. (Refer to recommendations) The home has good systems in place for assessing service users abilities and needs regarding managing their own finances. Twenty six service users currently ask the home to keep small amounts of money safe for them, and a system is in place for safely storing and accounting for this money. Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 Page 22 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 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x 3 x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 x x x Alexander Care Centre DS0000007002.V250060.R01.S.doc Version 5.0 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. 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 The registered manager must ensure that risk assessments for all service users and guidance for staff are more detailed especially in relation to falls The registered manager must ensure that all service user plans include details of how social care needs are to be met and reviewed The registered manager must ensure that social and leisure activities are developed in full consultation with service users and reflect their assessed needs The registered manager must ensure that the outcome of all complaints is communicated to complainants within 28 days, or reasons for delay is communicated to them. The outcome of the current outstanding complaint must be DS0000007002.V250060.R01.S.doc Timescale for action 28/02/06 2 OP7 13(4) 31/12/05 3 OP7 15 (2)(c,d) 28/02/06 4 OP12 16 (2)(m,n) 28/02/06 5 OP16 22(3,4) 31/10/05 Alexander Care Centre Version 5.0 Page 24 6 OP16 22 (3,4) 7 OP33 24 (1,2,3) communicated to the complainant as soon as possible. The registered manager must 31/10/05 develop a clear system for keeping track of complaints to ensure timely resolution of complaints. The registered provider and 28/02/06 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. 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 OP1 Good Practice Recommendations The registered manager should consider ways for involving service users in future reviews of the homes Statement of Purpose and Service User Guide, and inform service users how this is to be done. The registered manager and provider should consider including Managing Diversity training in the training plan for all staff The registered manager should acquire a copy of the report of the recent pharmacists inspection and ensure that any requirements or recommendations are acted on. The registered manager should consider means of providing service users relatives with overnight accommodation in the home in cases of serious need, or provide information regarding local accommodation available The registered provider and manager should consider how it will involve service users in the development of it’s business plan, and communicate this to service users 2 3 4 OP4 OP9 OP13 5 OP33 Alexander Care Centre DS0000007002.V250060.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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