Inspection on 07/04/08 for Alexander Court Nursing Home

This inspection was carried out on 7th April 2008.

CSCI found this care home to be providing an Adequate service.

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 Court Nursing Home 13/04/07

Alexander Court Nursing Home 25/04/06

Alexander Court Nursing Home 24/01/06

Alexander Court Nursing Home 13/04/05

Alexander Court Nursing Home 04/08/04

Alexander Court Nursing Home 04/05/04

Alexander Court Nursing Home 19/12/03

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

CARE HOMES FOR OLDER PEOPLE Alexander Court Nursing Home 2 Lydgate Court Crookes Sheffield South Yorkshire S10 5FJ Lead Inspector Sue Turner Key Unannounced Inspection 7th April 2008 07:45 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 Court Nursing Home DS0000021763.V360942.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. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander Court Nursing Home Address 2 Lydgate Court Crookes Sheffield South Yorkshire S10 5FJ 0114 268 2937 0114 268 2945 alexandercourt@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd 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) Mr Andrew John Mann Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 60 13th April 2007 2. Date of last inspection Brief Description of the Service: Alexander Court is a purpose built home for older people, which provide 60 places for people with personal and nursing care needs. All bedrooms have an en-suite facility. It is in a residential area of Sheffield with good access to public services and amenities for example shops, pubs, and public transport. It is built on three levels serviced by a lift. The home has single and double rooms and a suitable number of lounges and dining rooms. The home has a car park and lawned areas. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 1st April 2008 were £351 - £637 per week. Additional charges included newspapers, hairdressing and private chiropody. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Sue Turner, regulation inspector. This site visit took place between the hours of 7.45 am and 3:30 pm. The operations manager is Helen Emery, who was present during the site visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. We only received one survey back from a relative. Comments and feedback from this has been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Eleven staff, four relatives and six people living in the home were spoken to. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in April 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was in the main good. They made comments such as: Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 6 “I’ve come to realise that this is a good home”. “Staff are very good and I feel safe living here”. “Staff are right enough”. Comments received from questionnaires and from talking to relatives were in the main positive and included: “Staff are brilliant” “The home is of a reasonably high standard – no more than I would expect for the high fees demanded”. “Staff keep us well informed, when we talk to them about mum, they are interested in what we have to say”. The inspector observed that people were well dressed in clean clothes and had received a good standard of personal care. People’s health care was monitored and access to health specialists was available. Staff were observed being respectful towards people. People said that they had a choice of food and that the quality of food served was “well cooked”, “enjoyable”, “satisfactory” and “alright”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? At the previous inspection twelve requirements were issued. At this inspection eleven of these requirements had been actioned and one had been partly actioned. People’s healthcare and personal care needs were being monitored. This information was placed in their care plans. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 7 People’s had been asked what their individual food preferences were. This was recorded and available for the catering staff to refer to. Mealtimes at the home had been restructured and people said they were receiving meals at a time convenient to them. There were sufficient numbers of competent and experienced staff on duty at all times. Over 50 of the care staff had been trained to NVQ Level 2 or above. A permanent manager had been employed at the home and he had registered with CSCI. Unfortunately the manager was on long-term leave of absence. Management cover was in place but the home was without a committed manager. Following the quality audit review action had been taken to address any issues raised by people who had contributed to the review. A copy of the review had been made available to CSCI and other interested people. 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. The summary of this inspection report can be made available in other formats on request. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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 Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 3. Standard 6 is not applicable to this home. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A statement of purpose and service user guide was available and contracts were drawn up with each person to inform them of their rights and obligations. Upon admission, proper provision was not in place for one person. This had not promoted their health and welfare. EVIDENCE: The homes Statement of Purpose and Service User Guide were available, both in the entrance hall, for anyone visiting the home and a copy was also in each persons room. These included useful information about the home and the services offered. Both the Statement of Purpose and Service User Guide had been updated accordingly. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 10 Each person had a written contract/statement of terms and conditions with the home. This provided important information that helped people to understand what they could expect from the service. Prior to admission taking place professionals and staff assessed people. Most referrals came from hospitals. Pre admission assessments were seen in people’s files. One relative spoken to said that he/she was feeling very aggrieved. Their relative had been assessed in hospital by staff from the home. At the assessment, he/she had been reassured that specialised equipment would be in place at the home when their loved one was admitted. The person had arrived at the home several days before and necessary equipment was not available. This had caused their loved one to become anxious and upset. We spoke to the operations manager who arranged for the necessary equipment to be delivered the following day. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, social and personal care needs were documented in the care plans and a range of health care professionals visited the home. Medication procedures protected people’s health and welfare. People and their relatives were complimentary about the way staff promoted their privacy and dignity. EVIDENCE: People living in the home had an individualised plan of care. Four peoples plans of care were checked. Care plans contained a full range of information. These contained information on aspects of personal, social and health care needs. Care plan formats consisted of many individual sheets of paper. Each related to a care need and staff either used numbers, codes or tick boxes to identify a persons needs. This made them very cumbersome and off-putting. Two Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 12 relatives spoken to said they had asked to see their mothers care plan but “weren’t able to understand any of it”. The operations manager was aware of the inappropriateness of the care plan formats and showed us a ‘personal preference plan’ which was to be introduced to make the care plans more person centred. The operations manager said that attempts had been made to try to involve relatives in care planning. A notice in the front entrance hall was on display, which prompted relatives to become involved in reviews. All relatives spoken to said they had not been invited to care planning reviews. Care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists visited the home as requested. Medicines were securely stored around the home in locked trolleys within cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Qualified nurses administered medications. There was evidence that managers and trained staff were auditing medication administration procedures. Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. Staff were observed speaking to people in a respectful way and showed empathy and patience when providing personal care to them. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. Weekly activities were displayed in the entrance hall. The home employed an activities worker who worked each day. Examples of the activities available were crafts, quizzes and reminiscing sessions. Outside entertainers occasionally visited the home and shopping trips were organised. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 14 On the day of the site visit the activities board said there would be news discussion, book club, reminiscence and literary day. During the morning we observed a small quiz and people sat listening to music. Relatives said: “The activities available are not suitable for mum so she chooses to spend time in her room with her talking books”. “Dad enjoys the quizzes and music, but there aren’t always activities suited to people with other needs”. People said that the meals at the home were “ OK”, “good” and “fine”. Menus were rotated on a four weekly basis. Choices were always available. The head cook had implemented a well balanced diet and was in the process of introducing the ‘Nutmeg’ system. This used the traffic light colours to identify that meals were nutritionally sound. The inspectors observed people over breakfast. Choices were available and staff were aware of peoples meal preferences. The tables looked very bare with tablecloths, which were heavily creased. There were no condiments, cutlery or crockery on the tables. Dining rooms were quite small and crowded which didn’t aid a homely ambience. Staff didn’t rush people but the dining room experience was one of getting the task over with. It was apparent that staff didn’t see this as an important social event for people living in the home. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced would be listened to. The majority of staff had received adult safeguarding training. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. Most people and relatives said they were able to speak to staff or managers if they were unhappy about something. Some relatives said that the changes in managers over the last few years had hindered them building up relationships, which had sometimes made it more difficult to raise concerns. The home kept a record of complaints, which detailed the action taken and outcomes. There was one outstanding complaint, which was being investigated by the operations manager. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 16 Since the last inspection we had received two concerns about the home. One was in relation to a persons fees, which was dealt with by other professionals. The other related to the constant turnover of managers at the home. The provider responded to this by placing a project manager at the home. The project manager will remain at the home until a full time permanent manager is in place. There have been two adult safeguarding referrals. The provider acted promptly to ensure that people living in the home were safe. These referrals are currently under investigation. An adult protection procedure was in place. The majority of staff had undertaken training on adult protection. A small number of staff had not completed adult protection training, even though they had been identified as requiring the training in 2006/7. People spoken to said that they felt safe living at the home. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and generally well maintained, providing a pleasant environment for people and their visitors. EVIDENCE: Since the last inspection some areas within the home had been refurbished and the AQAA stated that the maintenance and renewal programme for the home would continue. The home was clean and tidy. Lounge and dining areas were domestically furnished and a tour of the building identified that some areas of the home were in need of repair and redecoration. A handy person was employed to help Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 18 maintain the environment. Some homely touches were provided, however some bathrooms and toilets looked quite bare. The windows were in a very poor state of repair. External frames were showing signs of rotting and deterioration. On some windows the double-glazing seal had failed causing condensation on the inside of the panes. Relatives said: “The home is clean and mostly odour free”. “Mum has just had a new carpet fitted in her room, it looks lovely”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet the needs of people. The recruitment information obtained for some staff was insufficient to adequately protect the welfare of people. Newly employed staff had completed induction training, however some staff required refresher training and specialist training to ensure their skills were kept up to date. EVIDENCE: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. They said that there was usually enough staff on duty and when people were sick, other staff or agency were called in. On the day of the site visit staffing numbers were at an acceptable level. People’s views about how quickly staff responded to them differed. One person said the staff responded quickly if she called them, one said staff sometimes took a long time to come and another person said that she always had to wait along time for staff to respond when she called them. One relative said: Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 20 “There may be a slight difficulty in that some staff are not fluent in English, however I have found them always pleasant, cheerful and willing to help”. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Staff were able to talk about the various training courses that they had attended, however for some staff updated and refreshers in mandatory training, for example, Moving and Handling and Adult Protection was necessary. The operations manager had recently undertaken a review of staff training and had identified the shortfalls. Further training in specialised topics for example diabetes and falls prevention was to be delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. Staff said that unstable management arrangements had affected their training programme. They said they had not been confident in asking about training, because of the many changes in managers. 52 of the care staff had achieved NVQ Level 2 or above in Health and Social Care. A number of care staff had also commenced the training. This met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Three staff records of employment were checked. There were shortfalls in the information that should have been gathered during the recruitment process. For one person a reference had not been obtained from their previous employer. Gaps in people’s employment records had not been checked out and for one person there was no photograph on file. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 21 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): Standards 31, 32, 33, 35, 36, 37 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The absence of a long-term permanent manager has meant that people and staff were not able to benefit from a clear sense of management and leadership. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. In the main people’s health and safety had been promoted and protected. EVIDENCE: At the previous inspection the report highlighted that: Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 22 Since November 2004 the home has not registered a permanent manager with CSCI. From 2004 to the present (2007) there have been a number of managers and acting managers that have left before they have become registered. On the day of the inspection a project manager, working for the organisation had taken the role of acting manager. Staff spoken to raised concerns about the many changes of managers and how this caused disruption and interference to working practises. The inspectors believe it is imperative that a permanent and stable manager is recruited to the post so that staff have a clear sense of direction and leadership. Following this the organisation recruited a permanent manager. It is most unfortunate that the manager is presently on long-term leave of absence, which has meant that the home continues to have unstable management arrangements. Whilst we acknowledge that the organisation is ensuring that the home does have management cover it is very apparent that people living in, working in and visiting the home are concerned about stability and consistency. The service provided at the home has not deteriorated and the recent input of the operations manager has resulted in there being a number of improvements to systems. However there is little evidence that the service is moving forward and ultimately improving outcomes for people living in the home. The AQAA stated many ways in which the home monitored the quality of the service offered. Twice yearly surveys were sent out to people who have an interest in the home and the results of these were published and acted upon. The operations manager carried out monthly visits to the home and provided a report. Staff, resident and relative meetings were held on a regular basis. The home handles money on behalf of some people. Account sheets were kept; receipts were seen for all transactions. Formal staff supervision, to develop, inform and support staff took place at regular intervals. Staff said that they found this useful and beneficial. During the site visit we observed an office that housed peoples files and personal information. The office was kept open and didn’t have a lockable door. This was brought to the attention of the operations manager who immediately arranged for the maintenance person to fit a lock. Equipment at the home was serviced and maintained. Fire records evidenced that fire alarm checks took place each week in line with the fire services recommendations. Staff said fire drill training took place on a regular basis and the inspector saw evidence of this. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 23 The company employed a person who was responsible for completing the fire risk assessment. The operations manager confirmed this had been recently completed and any areas of concern were being actioned as a matter of urgency. Staff said that they had been provided with one stand hoist and one sling hoist for each floor. They said that due to the dependency needs of people there was a need for a further hoist. Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 24 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 3 3 3 Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 25 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 12 Requirement So that people’s health and welfare is not put at risk proper provision for their care must be in place upon their admission to the home. People and/or their representative must be involved in the care planning and reviewing process. (Previous timescale of 01/06/07 partly met) 3. OP18 18 To ensure that people are protected all staff must undertake training in adult safeguarding. There must be a thorough recruitment procedure, based on ensuring the protection of people. Therefore: References must be obtained from previous employers. Staff files must contain full and accurate dates of previous employment. Files must evidence that gaps in employment history have been explored. DS0000021763.V360942.R01.S.doc Timescale for action 07/04/08 2. OP7 15 01/05/08 01/06/08 4. OP29 17 19 07/04/08 Alexander Court Nursing Home Version 5.2 Page 26 5. OP30 18 6. OP31 30 Staff files must contain a photograph. All staff must be provided with the relevant specialist and mandatory training for the role they are to perform. A review of the management arrangements must be undertaken. Action must be taken to ensure that there is a permanent manager in post at the home. 01/06/08 01/06/08 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. 2. Refer to Standard OP7 OP12 Good Practice Recommendations Care plans should be reviewed so that information recorded is person centred. People should be consulted regarding the type of activities they would enjoy. Further activities and trips out of the home should be provided, to ensure that peoples social and recreational needs are met. Meals should be pleasant experience. More thought should be given to improving the table settings and the general ambience in the dining rooms. External windows and frames should be repaired or replaced. Another stand hoist should be provided. 3. 4. 5. OP15 OP19 OP38 Alexander Court Nursing Home DS0000021763.V360942.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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. 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