CARE HOME ADULTS 18-65
Alexander Family Nursing Home Oakhurst 1 Parker Close Carshalton Surrey SM5 3HF Lead Inspector
Alison Ford Key Unannounced Inspection 28th August 2007 10:30 Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Alexander Family Nursing Home Address Oakhurst 1 Parker Close Carshalton Surrey SM5 3HF 020 8669 1111 020 8669 7070 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) Mrs Denise Deroy Parker vacant post Care Home 18 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Terminally ill (0) of places Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow service users currently residing in the home who are over the age of 65 to be accommodated until such time that the home is no longer able to meet their needs or their placement ceases. A maximum of four service users over the age of 65 may be accommodated in specified rooms on the lower ground floor. 20th December 2006 2. Date of last inspection Brief Description of the Service: Alexander Family Home is an attractive chalet style residence in Carshalton, designed and adapted by the proprietor, originally to suit the needs of a relative. As it was a private home it has retained a very comfortable and homely atmosphere. Now registered as a care home it provides accommodation for up to eighteen residents who may have physical or learning disabilities or be terminally ill, four of who may be over the age of 65. The home is situated close to the centre of town and is well served by public transport links. Accommodation is provided over two floors and consists of five double and eight single bedrooms all with en-suite facilities and there are also assisted baths on each floor. A large dining room is adjacent to the kitchen and there is a lounge on each floor, one of which opens onto a well-maintained garden. The proprietor of the home is very involved in its running and she and her team are committed to providing a high standard of care within a family type environment. At the time of this inspection information regarding fees payable was not available. A copy of the homes Statement of Purpose, Service User Guide and the latest inspection report can be obtained from the home. Inspection reports can also be obtained from The Commission for Social Care Inspection via the internet. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first key inspection visit as part of the inspection process for the year 2007/2008 and was unannounced. It took place over two days, as some information was not available on the first day. When writing this report, consideration has also been given to other information gathered throughout the year such as, records of incidents and accidents, complaints and other documentation required to be kept by the home as evidence of its commitment to the health and safety of the people who use the service. There have also been conversations with residents, their relatives and members of staff. Prior to the visits the homes Registered Provider had submitted an Annual Quality Assurance Assessment (AQAA). This is a document that is completed by The Providers and supplies information about the home, giving information about how well they consider they meet the needs of the people who use this service and their future plans. This home is registered with The Commission for Social Care Inspection to provide care for adults age 18-65 although a previous variation was in place to allow older people who were already living there to remain. However, currently more than 50 of those living there are over the age of 65. Discussions will need to take place in order to clarify this situation. On both days that visits were made there were 13 residents living in the home. One trained nurse was on duty with three care staff, supported by a cook, domestic and maintenance staff. During the inspection a tour of the premises was undertaken; a sample of care plans were assessed, documentation relating to health and safety was seen and several of the residents and one relative, who was visiting, were spoken with. Menus and kitchen records were seen and the lunchtime meal was served during the visit on the first day. Two additional visits have been made since the last inspection; one with the Fire Safety Officer to discuss the arrangements in the home to comply with fire safety legislation, the other to undertake a review of one of the people who use the service. One complaint has been received about the service since the last visit and concerns were raised at this inspection regarding a service user who has been admitted who is not within the agreed category of registration.
Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
Since the last inspection some redecorating has been undertaken and new carpets are being laid throughout the home. In response to a previous concern a new complaints book has been introduced and this is left in the hall. It will be monitored regularly to ensure that any concerns are addressed promptly. A new quality assurance questionnaire has been produced. This has been left in the entrance hall to invite comments about how well the service is performing and meeting the needs of those who use it however, there was not any available evidence to show how else it was being distributed. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 7 Staff training has been ongoing with some staff attending sessions concerned with palliative care so that they can improve the care given to residents and their families at the end of their lives. What they could do better:
Pre admission assessments of new residents do not provide sufficient evidence of how the home intends to meet their needs. The assessment must be able to demonstrate the ability of the staff and the services that are provided, to meet the needs of any one who lives there. Attention is given to physical disabilities that potential residents may have however, given that several resident have difficulty communicating and also include those from specific ethnic minority communities there is very little information regarding how social, psychological or cultural needs will be Concerns were raised about the admission of one resident whose identified care needs fall outside the registration category for the home. This will be addressed as a separate issue. The home will need to provide evidence of its ability to meet the residents needs and if it is considered appropriate a variation of registration will need to be applied for. People who may be considering moving into the home need to be able to access sufficient information to help them decide if it will suit them. Therefore, The Service User Guide needs to be amended in line with regulations to ensure that it contains all of the information that they might need. In order to ensure that help and support that is given to residents is in line with their preferences, they and their relatives or representatives must be given the opportunity to contribute to their care plans so that they can be sure that they are being cared for in a way which suits them. The range of activities that are offered to residents must be increased in line with their preferences and abilities, they are currently very limited and it was noted during the inspection visits that people sit around in the lounge and little is offered in the way of stimulation for them. One resident spoken with said that they would enjoy more activities that were music based. The home still has no registered manager. This role is essential to provide leadership for staff and effective day-to-day running of the home in which the aims and objectives of the home are achieved. Some concerns were noted regarding the complaints procedure. Although it is acknowledged that an appropriate procedure is in place, it is not in a format Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 8 that would easily be understood by the majority of those people who use the service. Consideration should be given to ensuring that any procedures that is intended should be used by those living in the home should be presented in a format which makes it accessible to them. 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 Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1,2,3 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The people who use this service do not have access to all of the information that would help them decide if the home was suitable for them and there is insufficient evidence available to show how their healthcare needs will be met. EVIDENCE: The Statement of Purpose for the home was seen and also a copy of the Service User Guide which is hanging outside each residents room. Despite previous requirements the Service User Guide still does not comply with current regulations. It does not contain a copy of the most recent inspection report and there is no information regarding the range of fees and extra charges that might be payable. The AQAA states that these would be discussed at the time of admission and based on individual need. However, this information must be available to any prospective service users when they are choosing whether the home might be suitable for them. Consideration must also be given to producing it a format, which is suitable for the people for whom it is intended. Two new residents had been admitted since the last inspection. Care managers assessments were available for them however, both of them had complex care Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 11 needs and the assessments undertaken by the home provided little evidence of how it was intended that these needs would be met. One resident had been admitted who was not within the homes registration category. This will be dealt with as a separate issue; if evidence can be provided as to how their assessed healthcare needs will be met a variation to registration will need to be applied for. Another new resident is unable to communicate in English. It was noted that there is often a member of staff on duty who can converse with them however there is not any evidence available to show that this was considered at the time. There was no evidence available to show that residents or their relatives or representatives are supported to be involved in this assessment process, that consideration has been given to their social and cultural needs or how there may be effective communication between them and staff. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service have an individual care plan however there is limited evidence available to suggest that they are encouraged to participate in the process. EVIDENCE: Each resident has an individual care plan and four of these were seen at this inspection. Basic healthcare needs are identified along with the support and interventions that are required and these are reviewed regularly. While it is acknowledged that the majority of those living in the home have complex care needs, there is little evidence to suggest that they or their families or representatives are involved in the development and review of the plans. One resident that was spoken with, asked “ what’s that all about” when shown a copy of their care plan.
Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 13 They are not available in a format that any of the residents could understand and limited information is available about their social needs and preferences. Some of the residents do have access to an advocacy service. It is considered that none of the people who use this service can control their own financial affairs and the Registered Provider is an appointee for nine of them. Accounts were seen and appeared to be in order and they are audited by the local authority. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards12, 13,14,15,16,17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service are able to enjoy a limited range of activities, which will provide stimulation and interest to their lives. Some of them are able to maintain their links with the local community and visitors are always welcome so that family relationships will be maintained. A well-balanced and varied diet is provided to ensure that resident’s nutritional needs are met. EVIDENCE: Residents living in this home are unable to work due to their complex care needs and, despite previous requirements, opportunities for them to participate in activities remain limited. Some residents are able to attend an art centre and another goes to a day centre. Some residents are able to go out
Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 15 of the home however this is generally dependent on friends or relatives being able to accompany them. Visitors are always welcome into the home and residents can see them in private if they wish or sit in one of the large and pleasant lounges. All residents have locks on their bedroom doors however; none have elected to use them. Staff interaction with residents is good. Many of them have been working there for some time and they enjoy a good relationship with them. All those that were spoken to agree that the food served within the home is of a high standard and the menus were seen to be varied and nutritious. The chef spends time talking to residents to establish their preferences and will always provide an alternative meal choice. The registered provider frequently joins residents for lunch, which is served at a large table to promote a congenial and homely setting. The kitchen area was observed to be clean and tidy and appropriate records were well kept although a record needs to be kept of the food that is actually eaten by residents on a daily basis as evidence that they are receiving a nutritious and well balanced diet. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards18, 19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service know that staff will support them with their healthcare needs in a sensitive manner. Procedures are in place for the safe ordering, administration and disposal of medication however these still need to be improved to simplify an audit trail, which would provide evidence of good practice. EVIDENCE: Personal support is provided to residents in private and they say that they are able to choose when they get up and go to bed. All rooms have en-suite facilities and there are hoists and other aids in use within the home in order to maintain independence. Advice is sought from other members of the multidisciplinary healthcare team, such as physiotherapists, and the Tissue Viability Nurse. Residents in this home generally have complex nursing needs, which they would be unable to manage themselves even if supported. Four care plans
Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 17 were seen at this visit and showed that regular reviews had taken place to ensure that interventions remained appropriate. Records of medication storage and administration were seen. As at previous inspections these were in order however, the procedures in use make an audit trail difficult to follow. Once ordered, medication may be kept in a store cupboard prior to being started, for varying lengths of time. The requirement is once again repeated that consideration must be given to simplifying this system to provide a clear audit trail, and MAR sheets must show on which day a new course of medication is commenced. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22,23, Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The people who use this service generally consider that any concerns that they might have will be addressed appropriately although the complaints procedure is not in a format that all of them would be able to understand. There is insufficient evidence available to show that appropriate checks are in place to ensure that residents are protected from harm. EVIDENCE: There is a clear and appropriate complaints policy which all residents and their families have access to although it is only produced in a standard format. It must be produced in a format / language appropriate for all residents. The complaints book is now kept in the entrance hall and was seen: there had not been any complaints since the last inspection. The AQAA states that appropriate checks and clearance have been undertaken on all staff members and there is an adult protection and whistle blowing policy within the home. Staff files that were seen did not all contain appropriate evidence that satisfactory clearance had been received prior to the start of employment. This is addressed under standard 34. There has been recent staff training in adult abuse awareness and this is going to be repeated in the near future.
Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 19 Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service live in a home, which is clean comfortable and well-maintained with specialist adaptations, which ensures that their needs are met. EVIDENCE: The home is an attractive chalet style house that has been designed and adapted to suit the needs of the residents and is in keeping with its surroundings. Bedrooms are spacious and three separate sitting areas provide an above average amount of communal space with suitable access for residents requiring wheelchairs. Residents all benefit from en-suite facilities and there are two assisted baths. The previous problems of accessibility within the home have now been solved as a passenger lift has been installed. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 21 The home was clean on the day of the inspection and is well maintained. Carpets throughout the home are in the process of being replaced. A sluicing disinfector has now been installed in line with current guidelines for the prevention of cross infection and contamination. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35,36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The people who use this service can generally be confident that staff will have the necessary skills and expertise to meet their needs. There is insufficient evidence available to show that robust recruitment procedures are in place. Some staff training has been undertaken to ensure that residents healthcare needs will be met however a lack of staff supervision means that future needs may not always be identified EVIDENCE: Many of the staff have worked in the home for some time and gained a great deal of experience in working with the residents. There has been an increased emphasis on training and staff confirmed that various sessions had been held throughout the year. The majority of the care staff now have an NVQ Level 2 qualification and others have completed a health and safety course. Others are undertaking training in palliative care and equality and diversity. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 23 Three new staff members have been appointed since the last inspection. Their files were seen however two did not contain copies of their clearance from the Protection of Vulnerable Adults Register. None of them contained written references. The AQAA states that appropriate pre-employment checks are made however there must be evidence of this in the home for inspection. Staff supervision is still not in place. This is essential to monitor staff performance and to identify future training needs. Training must be put in place to allow supervision and performance appraisal to take place for all staff. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39,42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that there is an intention to run the home in their best interests however the lack of a Registered Manager means that effective day to day running of the home is compromised. The continued lack of an efficient quality assurance monitoring system means that residents are not able contribute to or influence the running of the home. Some working practices are insufficient to ensure the protection of residents. EVIDENCE: This home is still without a Registered Manager although apparently an advertisement has been placed. This situation has been ongoing for at least three years with a brief interlude when a manager was in post.
Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 25 This is an essential role, which provides leadership and clear lines of accountability for staff and continuity of care for residents therefore a suitable person must be put forward for registration with the Commission for Social Care Inspection without delay. Previous inspections highlighted the need to find a way to monitor the views of the people who use the service. Attempts to gain information from questionnaires have apparently not been successful in the past. A new questionnaire has now been devised although there was no evidence to show that any responses had been obtained. It would seem to be left in the home for visitors to pick up, no information was available to suggest that it had been actively promoted. Consideration must be given to distributing it to a wider audience such as care managers, advocates and other healthcare professionals who visit the home. A fire risk assessment has now been produced which has apparently been approved by the Fire Safety Officer however; this is kept in a large file with other documentation. The risk assessment must be available as a “stand alone” document which can be given to emergency services in the event of a fire and to new staff members or other visitors to the home as required. It was noted that not all areas have signs depicting the nearest fire exits. Although detailed plans of the home have been put up theses are quite complicated and it is unlikely that visitors to the home would look at them in any great detail. It is recommended that signage should be increased. Fire training has now been arranged for staff. It is also recommended that some information should be put up alerting staff and visitors as the actions that should be taken in the event of discovering a fire. The AQAA states that all necessary maintenance checks have been completed appropriately and policies and procedures concerned with the health and safety of the people who use the service are in place. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 2 1 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 2 X Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 5 (1)(bb) Requirement The Service User Guide must provide information regarding fees payable to residents, in line with the Regulations so that they are able to access all of the information that they might need to decide if the home is suitable for them. Only those people whose care needs fall within the registration category of the home may be admitted. Pre-admission assessments must provide evidence that a full needs assessment has been carried out and prospective service users have been encouraged to contribute to this process. There must be evidence available to demonstrate the ability of the home to met the healthcare needs of prospective residents. There must be evidence available to demonstrate how people who use the service have been encouraged to contribute to their care plans.
DS0000019070.V349016.R01.S.doc Timescale for action 30/11/07 2 YA2 16(1) 28/08/07 3 YA2 14(1)(c) 28/08/07 4 YA3 15(1) 28/08/07 5 YA6 15(1) 30/11/07 Alexander Family Nursing Home Version 5.2 Page 28 6 YA14 16(2)(n) 7 YA20 13(2) A range of activities must be provided for residents, which suits their preferences and capabilities. The Responsible Person must ensure that medication storage and administration is arranged in such a way as to show a clear audit trail. Previous timescale 30/03/07 not achieved. The complaints procedure must be produced in a format/language to allow all of those people living in the home to be able to access it. There must be evidence available for inspection to show that pre-employment checks have been completed in line with Schedule2 All staff must receive supervision and performance appraisal on a regular basis. A suitably experienced and qualified person must be put forward to be registered as the manager of the home. Previous timescale 30/03/07 not achieved There must be evidence that every effort has been made in order to gain the views of those who use the service as to whether it is meeting their needs. The fire risk assessment must be produced as a stand-alone document that can be given to the emergency services, new members of staff and any other visitors to the home who may need it. 30/11/07 30/11/07 8 YA22 22(2) 30/11/07 9 YA34 Schedule 2 28/08/07 10 11 YA36 YA37 18(2) 8(1)(iii) 30/11/07 30/11/07 12 YA39 24(1) 30/11/07 13 YA42 23(4) 30/11/07 Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 29 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 YA42 YA42 Good Practice Recommendations It is recommended that signage regarding fire exits be increased. It is recommended that information regarding the actions to be taken on discovering a fire should be available throughout the home. Alexander Family Nursing Home DS0000019070.V349016.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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
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