Inspection on 05/09/07 for Alexander Heights

This inspection was carried out on 5th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Heights 30/06/09

Alexander Heights 19/08/08

Alexander Heights 21/09/06

Alexander Heights 06/12/05

Alexander Heights 11/07/05

Alexander Heights 17/02/05

Alexander Heights 21/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Alexander Heights Alexander Heights Winsley Hill Limpley Stoke Bath BA2 7FF Lead Inspector Alison Duffy Unannounced Inspection 09:20 5 September 2007 th 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 Heights DS0000028312.V339169.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 Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander Heights Address Alexander Heights Winsley Hill Limpley Stoke Bath BA2 7FF 01225 722888 01225 723017 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) Avonpark Care Centre Limited Jean Carole Chapman Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2006 Brief Description of the Service: Alexander Heights is a residential care home registered to care for 28 older people. The home is not registered for Nursing Care. Intermediate Care is not provided. The home is located within a Care Village in Limpley Stoke near Bath. The accommodation is on the first floor of a purpose built unit. Access is gained via a passenger lift or stairs. There is a terraced area, adjoining the airconditioned conservatory style lounge. Residents have access, if they are independent or have support, to well-maintained gardens at ground level. There is a small shop, library and a GPs surgery within the complex. Residents have their own room with an en-suite facility. Communal areas consist of the conservatory, a separate dining room, a games room and two lounges. There is a central kitchen and all laundry is undertaken within facilities also used by other units on site. Staffing levels are maintained at three members of care staff on duty throughout the waking day. There are also domestic staff and an activities organiser. A member of staff is employed for the servery to serve breakfast, lunch and supper. The manager is on duty Monday to Friday and is able to assist when required. The complex provides central catering, laundry and maintenance staff. At night there are two waking night staff and an on call management system. Mrs Jean Chapman is the registered manager. Mrs Chapman has been in post since May 2006. Ms Chapman has worked in the care sector for 25 years, 7 of those in a managerial role. The fees for the home are dependent on the size of the room occupied and the individual needs of the resident. This ranges, on a weekly basis from £530.00, up to £1000.00, for a suite, which includes a sitting room. Additional charges for chiropody, hairdressing and personal items apply. Residents are able to access domiciliary care, physiotherapy and other services, as they would do in their own home. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place initially on the 5th September 2007 between the hours of 9.20am and 6.20pm. Mrs Chapman was on annual leave although visited the home and spoke briefly with the inspector. Ms Sarah Robinson, Head of Care, was available throughout the inspection and received feedback at the end of the day. Ms Robinson had taken responsibility for the day-to-day management of the home in Mrs Chapman’s absence. A second day was arranged to complete the inspection. This took place on the 19th September 2007 between 9.30am and 3.30pm. Mrs Chapman, was available throughout. At the start of the inspection, discussion took place with Ms Robinson regarding current care provision. The inspector then met with a number of residents in the privacy of their own rooms. A tour of the accommodation was made and the medication systems were examined. The lunchtime meal was observed and discussion was held with some staff. The inspector then viewed care planning information, daily records, staffing rosters and staff recruitment documentation. The management of some residents’ personal monies for safekeeping was examined. On the second day of the inspection, further discussion took place with residents and staff. Training records, health and safety material and the complaints log were viewed. As part of the inspection process, surveys were sent to the home to distribute. Mrs Chapman distributed these to residents and health care professionals. CSCI sent surveys to each resident’s primary relative. The feedback received is detailed within the main text of this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Residents are enabled to follow their preferred routines. For example, they are able to get up when they wish, spend time in their rooms and have visitors as required. A varied menu is available and clearly displayed. A separate menu is in place for specialised diets. All meals consist of three courses and there is a choice of each meal. Fresh drinking water or fruit juice is available, within residents’ own rooms. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 6 GP’s and District Nurses visit the home on a structured basis and as required. Residents therefore gain regular input and their health is closely monitored. Residents are clear about raising their concerns and are confident, to address issues with the manager or staff. Positive relationships between residents and staff are in place. What has improved since the last inspection? What they could do better: While care plans have been developed, staff continue to record phrases such as ‘client needs staff to orientate her’ and ‘check XX during the day.’ Mrs Chapman was advised to ensure staff record clear, specific information, which demonstrates exactly what support the resident requires. Staff are evidencing the care given to a resident who has a pressure sore. However, preventative measures to minimise the risk of developing a sore are limited. Documentation does not give a clear audit trail of the skin deterioration. The information, which describes the pressure sore, is also conflicting within various parts of the care plan. Despite the resident being at risk of skin breakdown, documentation does not evidence prompt action to minimise any potential deterioration. Staff require clear information regarding the areas they need to be monitoring. Tissue viability training is therefore required. Despite a requirement at the last inspection to review staffing levels, there remains three care staff on duty during the waking day. At night there are two waking night staff. Staffing levels therefore remain at a minimum. Feedback Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 7 from some relatives, confirm staffing levels as an area that would benefit from improvement. This would enhance, the level of individual time available with residents. An activity organiser is deployed for 16 hours a week. Some care staff also organise some activities. Greater focus on residents’ individual preferred interests and involvement in the local community would enable greater opportunities for some residents. Medication systems are ordered and well maintained. However, staff must ensure that they adhere to the home’s policies and procedures to minimise the risk of error. Guidelines for staff regarding the use of equipment, such as oxygen or a nebuliser, must be stated within the resident’s care plan. Documentation must be available within the home to demonstrate that adequate fire safety checks are being undertaken. 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 Heights DS0000028312.V339169.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 Heights DS0000028312.V339169.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure ensures that prospective residents are assessed in their own home, before a placement is considered. Residents and their families are encouraged to visit Alexander Heights to ensure it is suitable and will meet the resident’s needs. EVIDENCE: Ms Robinson said she has started accompanying Mrs Chapman on initial assessments of prospective residents. Ms Robinson described the admission process of the two newest residents in detail. The assessment documentation of these residents was viewed. Both contained information related to physical and health care needs. The sections on religious needs, social interests and aspirations were not completed within one assessment. One file contained a discharge summary from hospital. There was also confirmation from a GP regarding the prospective resident’s health care needs. Mrs Chapman said she Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 10 gains the GP’s opinion, as to whether the resident meets the criteria of residential care. Within comment cards, seven residents said they received enough information about the home, before taking up residency. One resident said they had insufficient information. Mrs Chapman said a welcome pack is sent out to all enquirers. All eight residents who returned their comment card said they had received a contract. A number of residents said their family had chosen the home for them. They had respected their son or daughters decision and had moved to the home without visiting. They confirmed this was their personal choice. They could have visited, if they had wanted to. All said they were satisfied with the choice their families had made. Ms Robinson said a number of residents have been transferred to other units within the care village. The dependency levels of the residents, during this inspection were therefore lower than the last inspection. Ms Robinson explained that if possible, residents are enabled to remain in the home until the end of their life. However, residents were transferred to other services, as it was anticipated their needs would be more appropriately met, in a more specialised setting. Ms Robinson said that one resident’s family has chosen to purchase additional staff support for their relative. This was identified on the resident’s care plan. The relative explained that this had been suggested, as a means to resolve a particular difficulty. The agreement had continued and was viewed by the relative, as a positive experience. One relative however, as a means to improve the home, stated within their comment card, ‘assess new residents before agreeing to let them stay. This is a residential home and needs to be used for residents who cannot manage on their own rather than needing nursing care and showing severe symptoms of dementia. When choosing Alexander Heights I was led to believe there would not be residents with dementia and there would be outings and activities to stimulate an active mind.’ This view was discussed with Mrs Chapman. Mrs Chapman explained that there are no residents with a diagnosis of dementia within the home. However, some residents may become forgetful due to their age. Alexander Heights does not provide intermediate care and therefore Standard 6 is not applicable to this service. Alexander Heights DS0000028312.V339169.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): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the content of some care plans have improved, greater clarity of the support required would ensure individual needs are fully met. Greater focus is required to ensure efficient systems in relation to tissue viability. Residents are at risk through staff not adhering to the home’s medication policies and procedures. Residents are treated with respect and their dignity is maintained. EVIDENCE: All residents have a care plan that is reviewed and updated on a monthly basis. Since the last inspection, a summary sheet has been devised. This gives an overview of individual need and the support required. The care plans continue however, to contain statements such as ‘staff to assist with washing and dressing’ and ‘staff to check during the day.’ This was discussed with Ms Robinson who was able to state exactly what such statements meant in practice. Ms Robinson was therefore advised to apply, this clarity within the care plans. One resident used oxygen and a nebuliser. This was stated within the care plan. A risk assessment was also in place. However, guidelines for staff regarding their intervention were not apparent. The resident confirmed Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 12 that staff helped them with the equipment yet this was not clear within documentation. Within the risk assessment, certain instructions regarding the oxygen’s use were highlighted. It was advised that such information should be stated within the care plan. Within one plan it was stated that the resident ‘suffers from short tem memory and dementia.’ The plan continued to state ‘client needs staff to orientate her on a daily basis.’ There was no further information about how this was achieved or how the resident’s condition affected her daily life. Again, Ms Robinson was able to explain this. Ms Robinson confirmed that all staff know residents extremely well. Due to this, she felt the care is often given but not explained or evidenced within documentation. This was applicable, when a relative stated that staff were investigating a specific wheelchair, to enable a very frail resident to go outside. There was no evidence of this within the resident’s care plan. Issues affecting residents’ quality of life were not evident with daily records. For example, staff recorded tasks such as getting dressed, taking medication and sleep patterns at night, but minimal information regarding quality issues, were identified. Life histories form part of the care plan. Of those plans viewed, family members had developed these. At the last inspection, a requirement was made to ensure that the resident or their family, are consulted and sign the care plan. Mrs Chapman explained, that residents and their relatives are invited to assist with the care plan. Subsequent to the inspection, Ms Beeson said ‘at the time of the inspection, neither residents nor their families had been asked to sign the individual care plan to agree with its contents.’ Also ‘as each care plan is reviewed, the resident and their relatives would be encouraged to assist with its contents and to sign their agreement that adequate care and support was being met.’ Each care plan contains a number of assessments. These identify the risk of falling and the risk of developing a pressure sore. Each resident has a manual handling assessment. Various assessments addressing dependency levels are in place. There are risk assessments in relation to the use of bed rails. These highlighted the need for regular monitoring although evidence of this was not apparent. One bed rail was not covered with a bumper. Ms Robinson stated that this should have been in place so agreed to investigate the matter before going off duty. On the second day of the inspection, Ms Robinson confirmed a new bumper was in situ. Within a daily record, an entry had been made identifying a resident trying to climb over a bed rail. There was no evidence that this had been investigated. Mrs Chapman explained she was not aware of the situation. She confirmed that the resident often prefers to get up, using the bottom end of the bed. The need for bed rails should therefore be investigated. Within one assessment, family members had agreed the use of bedrails. It was advised that a health care professional should authorise the bed rails’ use. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 13 As good practise, aspects such as the resident’s choice of a male or female carer, to provide intimate personal care was stated. Offering a wheelchair if the resident appeared breathless when walking, was also identified. Medication profiles within care plans clearly identified each prescribed medication and the reason for its use. Residents are weighed on a monthly basis and records are maintained. Ms Robinson reported that ‘sit on scales’ have recently been purchased. When meeting one resident it was evident that their plan was not entirely up to date. The care plan was minimal in respect of the resident’s high level of need. There were no guidelines for staff as to how the resident was to be supported to eat or drink. Within the resident’s room, staff were maintaining records of food and fluid intake. It was advised that the amounts are totalled for each day and monitored. The resident was receiving support from a district nurse for a pressure sore. Due to documentation not being specific, an audit trail of the skin deterioration could not be identified. Entries such as ‘creamed pressure sore areas’ were stated. This gave insufficient clarity. A risk assessment highlighted a high risk of developing a sore yet preventative measures within the care plan were not clear. Different parts of the care plan gave conflicting information in relation to the extent of the pressure sore. Within a body chart two pressure sores were stated. Various gradings of the pressure sore were also stated. The daily records highlighted that the manager of the nursing unit had been asked to view the sores. They advised a dressing and a regime of changing the residents’ position. This intervention was clearly recorded within records kept in the resident’s room. The district nurse was involved two days later. Mrs Chapman confirmed that staff often utilise the skills and knowledge of the registered nurses on site, as an immediate response. This is then followed up through the community nurses. Within the care plan, there was no evidence of the intervention needed to minimise, further breakdown of other pressure areas. An entry within a daily record stated ‘soreness to side of feet’ yet there was no follow up action. Ms Robinson agreed to immediately review the resident’s care plan and inform staff of what they needed to be aware of. Within comment cards five residents said they always receive the care and support they need. Three said usually. Specific comments included ‘normally, virtually always,’ ‘I am happy here. I feel safe and well cared for’ and ‘the staff are usually very good.’ Four residents said they always receive the medical support they need. Four said they usually do. One relative commented ‘the standard of care is good.’ Mrs Chapman reported good relationships are maintained with health care professionals. Designated GPs and community nurses, visit the home on a regular basis. A chiropodist and optician also visit. Specialised services, such as a dietician are accessed as required. Residents’ families are encouraged to Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 14 support residents with any outpatient appointments. Alternatively, hospital transport or the LINK transport scheme is accessed. Three health care professionals responded to comment cards. Specific comments included ‘very impressed generally. I visit twice weekly. Care is of a high standard but their holistic care is good too. Staff are hard working but gentle and kind with the residents.’ Also ‘I have had a very positive and supportive response from the staff and particularly the manager of the home. They are always prepared to accommodate my requests and advice is always followed up.’ At the last inspection, hot drinks were located in thermos flasks in the lounge. Some residents were unable to manage the flasks. Others felt it was inconvenient to walk to the lounge, so did not do so. This impacted on residents’ fluid intake. A requirement was made to address this. In response, a drinks trolley has been introduced. Residents have hot drinks delivered to their rooms at key times. They also have a jug of water or fruit juice, if they wish. At this present time there are no residents, who manage their own medication. All medication is kept in locked cupboards within the ‘treatment room.’ Some bulk ordering of medication is undertaken. This is signed by the GP and has been agreed with a CSCI Pharmacy Inspector. The medication administration sheets were well maintained. Ms Robinson is in the process of placing residents’ photographs on the medication records to minimise the risk of error. As good practice, the areas topical creams need to be applied were stated. Following a requirement at the last inspection, the application of topical creams, is now evidenced. Eye drops and medications with a short shelf life had been dated when opened. Two residents are prescribed anticoagulant therapy. Ms Robinson reported that the GP usually confirms any change of dosage in writing. The district nurse may also give the information verbally when she visits. It was recommended that on such occasions, the district nurse should document the change of dosage on the medication administration record. If this is not possible, an alternate form of written communication should be used. A written procedure for this medication should also be in place. Some medication is prescribed, ‘as required.’ There was no evidence within care plans, as to what prompts an administration. Ms Robinson reported she would address this accordingly. When talking to one resident, they showed the inspector medication, which they had been given to take. The resident explained that they did not recognise it, so left it on their table. On examination of the medication administration record, it was confirmed that this medication was not that of the resident. An error had been made. The member of staff said they had realised this and removed the medication before it was taken. Ms Robinson reported the error to Ms Beeson, the Fit Person for Care Homes. Ms Beeson informed Ms Robinson that additional training would be given. During the inspection, staff were observed to engage with residents. Those residents seen were well groomed. One relative however, stated ‘my XX is Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 15 usually clean and tidy although some of his/her clothing is not presentable or clean. I am aware this may be down to him/her but with encouragement, this could be improved.’ Domestic staff were observed to knock on residents’ bedroom doors and wait to be invited in. Residents’ preferred form of address was stated within care plans. Residents expressed satisfaction with the ways in which staff interacted with them. One relative confirmed that the staff treated their XX with dignity and respect. Another said ‘staff respect individual wishes.’ Three health care professionals confirmed dignity and respect is maintained. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The experiences of some, confirmed that they would like greater social opportunities and to go out more often. Residents are encouraged to follow their preferred routines and have visitors when they wish. An extensive menu is available giving choice and a varied selection of food. EVIDENCE: The home has an activities organiser who undertakes 16 hours a week. One resident confirmed this and said ‘she’s away for a week so we’re having a rest.’ The resident said ‘its only a few of us who join in, as many can’t because of their memory. Quizzes are hopeless but sometimes we do bingo and XX [the activities organiser] does my nails. She sometimes takes some of them [residents] in the garden.’ Many residents spoken with explained that they were content in their own room. They enjoyed watching television, reading or taking a rest. One resident said they enjoyed a regular game of scrabble with their friends. They also spoke of having coffee with friends who lived within the sheltered housing complex in the care village. On the first day of the inspection, a member of care staff was organising an exercise group. Mrs Chapman confirmed that another member of staff supports Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 17 some residents with following horse racing. A fortnightly buffet with invitations to family members has been introduced. One resident said they regularly went out in the garden. They were grateful for their level of independence, which enabled them to do this. Other residents said they did not go out unless with family members. One resident explained that they had not been out since moving in to the home. They said ‘this isn’t a criticism, as I’m content to stay in here.’ One resident, explained that without friends and family, personal shopping would be a problem. They said that a bus service was available from the care village although confirmed ‘you would need to be fit and able to use it.’ One resident spoke of trips out in the past. They explained that while they had been enjoyable, the events had taken a lot of organising. They felt this was an extra strain on the staff, which was unnecessary. Within comment cards, residents stated ‘I never want to take part although I am encouraged and invited,’ ‘they’re there if needed’ and ‘varied and stimulating, external trips if weather improves.’ One relative stated ‘the atmosphere is not stimulating for elderly people who are intelligent and enjoy culture. However the staff are caring and kind.’ As an improvement, one relative suggested ‘I should love to see more cultural opportunities for those not able to move around e.g. visiting speakers, musical events. I should also love to see someone take my XX down to the garden sometimes – XX never goes if I don’t take her/him.’ Mrs Chapman confirmed that such activities do take place. She continued to report that a recent speaker spoke of Bath and its history. Subsequent to the inspection, Ms Beeson reported ‘residents are frequently asked for their ideas or suggestions with regards to their choice of activities.’ Further comments included ‘unfortunately as my XX is so alert mentally, he/she does find it very frustrating to be surrounded by many residents who are not. My XX needs ‘sensible conversation and more stimulating activities although this can be difficult with so many residents needing a lot of care and being unable to participate in activities.’ Also ‘my XX is cared for adequately. However as someone who has led an active life – physically and mentally, I feel the home lacks opportunity for him/her. There are many intelligent residents there who deserve more stimulating activities than those on offer.’ As a means to improve the service, within a comment card, a staff member stated ‘organise better social life for the residents. The company should buy a minibus for disabled in wheelchairs.’ It was suggested, as a means to further improve activity provision that individual interests, as identified in life histories are taken into account. Further external activity, should also be considered as this was raised by some residents. Mrs Chapman reported that suggestions for additional activities have been requested during residents’ meetings. However, none have been made. Mrs Chapman reported that a review of activities has found that more sessions are undertaken, than previously thought. She confirmed residents often go out in the garden with staff. Also the activities organiser undertakes a high level of Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 18 individual work, such as manicures, with residents. A key worker system has been introduced. Activities taking place are now documented. Within an activity sheet, which covered a period of a week, quoits, a party and two manicure sessions were documented. At the last inspection, it was noted that the Service User’s Guide, confirmed Alexander Heights has weekly outings and extra outings are arranged on the activities programme. Clarification was advised, as in practice, there was no evidence of these events. Changes have not been made to the documentation. The Statement of Purpose also states ‘We have regular organised outings which include outings to local areas via the company mini bus.’ This information must be reviewed, as it does not reflect resident and relatives’ experiences. At various times of the inspection, a number of residents were laid on their beds, resting or watching television. All said they could get up and go to bed when they wanted to. Mrs Chapman confirmed that residents are able to stay in their rooms as they wish. Staff respected individual choice of residents remaining in their nightclothes during the day. One resident was feeling unwell so was having a lie in. Another explained they felt safe in their room. Two residents explained that staff had initially gently pressurised them to join in with others in the lounge. They said they refused and now staff respect their wishes. One resident explained that they choose exactly what they want to do. They said ‘I pay a lot for living here, so I am going to do as I like.’ A member of staff confirmed residents’ choices are promoted. They explained that one resident, is never disturbed in the morning as they are not a ‘morning person.’ Residents confirmed that they could have visitors as they wish. A number spoke of distant relatives who they keep in touch with by telephone. Many residents have their own telephone in their room. One relative said they can visit at any time and are made to feel welcome. They explained that staff look after visitors and support them with any emotional challenges that may take place. All food is cooked in the care village’s central kitchen. It is then transferred up to the home in a ‘dumb waiter.’ Each meal consists of three courses. There is also a choice of each meal. Residents are able to choose what they would like, on menu cards, the day before. All residents spoke favourably about the food. One said ‘that’s my only complaint, we get too much food.’ Another said they have a large breakfast and tea, but skip lunch. They have ice cream instead. One resident expressed general satisfaction with the food although explained that the cooks often run out of different things. They also commented that the duration of the meal is lengthy. They explained everyone is kept waiting for all to be seated and there is a long wait between courses. This has arisen at previous inspections. The time span of meals was also raised within a comment card, from a relative. The inspector observed that residents were making their way to the dining room for 12.45pm. The first course was served at 12.50pm. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 19 The full meal and coffee was concluded by 1.30pm. The mealtime therefore appeared to run smoothly and was satisfactory, on this occasion. A member of staff confirmed that sometimes, although not often, they might need to wait for the food delivery. Mrs Chapman stated that timescales have been discussed with the catering staff. One resident said the dining room could be made more pleasurable. They explained that the room gets very crowded and hot. There is often a glare from the large windows and many disputes are held whether the windows should be open or shut. Mrs Chapman confirmed that blinds have been purchased to minimise the potential glare from the windows. Within comment cards, one resident said they always like the meals. Six said usually and one said sometimes. Specific comments included ‘too much ice cream,’ ‘could be more varied – not sure we get offered the full choice available’ and ‘far too much food.’ These comments were passed to Mrs Chapman for her attention. Mrs Chapman confirmed that food is now discussed regularly within residents’ meetings. The chef is often asked to attend so that feedback can be shared. There were various positive comments about the food from relatives. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are clear about the ways in which to give their comments and raise any concerns. Recent staff training in adult protection has further safeguarded residents from abuse. EVIDENCE: All residents spoken with said they would tell Jean [the manager] or a member of staff if they were unhappy. One resident said they would inform their family. One resident said ‘too true, I’d tell them.’ Another said ‘Jean is very good. She’d sort things out if she could.’ Comment cards confirmed that all eight residents who responded knew how to make a complaint. They confirmed [I would speak to] ‘Jean the manager and Sarah my key worker’ and ‘I am never unhappy. If I was, I would speak to the manager Jean or any of the staff.’ A relative confirmed ‘the manager and senior staff respond well when issues are raised.’ A complaint log is maintained. Since the last inspection, two complaints have been reported to CSCI. The organisation investigated the complaints and found no evidence to uphold them. There was a record of the complaints and the home’s response, in the complaint log. When investigating a complaint, Mrs Chapman was advised to clearly specify the outcome of each aspect. For example, documentation should state whether the complaint was upheld, not upheld or not substantiated. The evidence used to decide upon each outcome should also be stated. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 21 Some staff have undertaken adult protection training. Additional training has been arranged for those, who missed the earlier sessions. Mrs Chapman confirmed that local reporting procedures are addressed within the training. Following a recommendation at the last inspection, these procedures are now clearly displayed on the notice board within the office. The home’s abuse policy is in need of updating, as it refers to in house investigations. Shortly after the inspection, Mrs Chapman confirmed this had been addressed. Within the inspection, staff were asked a hypothetical question about abuse. They said they would inform the senior carer, the manager or the on call manager. Mrs Chapman confirmed this as appropriate practice and stated that senior managers would refer the incident to the necessary personnel. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents will significantly benefit from the refurbishment of the main corridor, which runs the length of the home. The environment remains warm and as residents are unable to independently control their room temperature, this is uncomfortable for some. Greater attention to cleanliness has improved the standard of hygiene within the home. EVIDENCE: Alexander Heights is located on the first floor and is therefore accessed via a passenger lift or stairs. All rooms provide singe occupancy and include an ensuite facility. This may be a toilet or a toilet and shower. Rooms vary in size and there is also a suite. The suite consists of a bedroom, sitting room and bathroom. There are additional communal bathrooms with assisted baths. Communal areas consist of a dining room and two communal lounges Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 23 At the last inspection, it was noted that there were areas, which would benefit from refurbishment. Ms Robinson reported that twelve residents’ bedrooms have since been redecorated. The corridor has been started although is awaiting new contractors to continue the work. Once completed, the area will be much improved. Ms Robinson confirmed that new lighting and a new carpet are planned. Ms Robinson said more residents’ rooms are due to be decorated. Within one comment card, one relative stated ‘we think that the room my XX has could be decorated with some refurbishment, as it may not be up to standard, compared to other rooms.’ Mrs Chapman explained that this could probably be the next room planned for refurbishment. Two carpets were showing sign of wear. Mrs Chapman reported that these are in the process of being replaced. At the last inspection, Ms Beeson, the Fit Person for the Care Homes, confirmed that the work to ensure residents, are able to regulate the temperature of their room, was in the process of being finalised. This had been identified as a requirement at a subsequent inspection. During this inspection, all radiators had covers, which restricted residents’ access to the regulator. Mrs Chapman explained that new valves had been fitted to all radiators to improve the quality of the heating. Mrs Chapman said she was not aware of the need for residents to have access to the thermostatic controls. Mrs Chapman said she would discuss the matter with the Fit Person for the Care Homes. Subsequent to this inspection, Ms Beeson reported that, at the previous inspection, she stated ‘within each room it would be possible to regulate the temperature.’ Ms Beeson continued to state ‘we can now confirm it is.’ Consideration must however be given to how residents are able to regulate the temperature of their room, as they wish. Within comment cards, one resident stated ‘difficult to regulate room temperature because of poor heating control – very old system, requires many trips from maintenance man to adjust radiator controls. Hence, response time very slow.’ Mrs Chapman and Ms Robinson both confirmed that staff are able to regulate the temperature. Visits from the maintenance person are therefore, no longer required. Residents should however, be able to control the temperature of their room, independently, if they wish to. A number of residents explained that their radiators had been turned off, as it was just too hot with them on. Within surveys three comments were received from staff about the temperature of the home. One said ‘too hot on the floor’ and another stated ‘the department I’m working on needs air conditioning as extremely hot. The radiators need to be turned off through the summer season.’ Also, ‘the central heating needs attention. It seems to be on most of the time in some rooms.’ Air conditioning units and fans are in place within the corridor yet the temperature during the inspection remained very warm. Two members of staff explained the environment is always very hot. Ms Robinson felt the temperature was personally, satisfactory. The temperature of the home has been an ongoing matter and consideration must be given, as to how it will be resolved. Following the inspection, Ms Beeson reported ‘the temperature of the Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 24 home has been given consideration and will be resolved once all of the new thermostatic controls are functioning correctly. This is currently being rectified.’ Further comments from relatives regarding the environment included ‘the home is very comfortable in communal areas’ and ‘we wrote to the manager about the hallway decorations about 2 years ago. At last this month they have started but we feel this should have been attended to 2 years ago. Also the lighting in the hallway needs improving.’ As a means to improve the service, one relative suggested a new large screen television. Another felt the outside patio area could be more pleasant. Mrs Chapman reported that the outside area was in the process of being addressed. There is a central laundry, which was not viewed on this occasion. At the time of the inspection, CSCI received an anonymous complaint about the laundry service. This involved a reduction in staff laundry hours and a lengthy timescale, before the return of residents’ laundry. Mrs Chapman confirmed there had been no changes to the laundry service. During this inspection, a number of residents expressed satisfaction with the laundry. However, one said ‘I often get things back that are not mine’ and ‘I’m all right, as I have lots of clothes. It might be a problem if I only had a few things because I would be waiting for things to come back.’ A relative also stated ‘the laundry service is improving but my XX has lost a number of items of clothing especially those we can’t label.’ Another stated ‘I would like to see my XX’s laundry done more often.’ At the last inspection, it was noted that there were some areas of the environment, which would benefit from greater cleaning. A requirement was made to implement specific cleaning schedules. Ms Robinson reported that areas have been delegated to specific individuals. Mrs Chapman said this has proved more successful. Within comments cards, there were varying views about cleanliness. One relative stated ‘good standard of cleanliness’ and ‘good cleaning of hallways and common areas.’ While another said ‘cleaning – very poor standard in occupied rooms’ and ‘I’d like to see my XX’s room cleaner.’ During the inspection, it was noted that the domestic had pulled a bed out from the wall and was hovering behind it. At this inspection, the standard of cleanliness appeared much improved. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels although maintained in line with the previous registration authority should be reviewed to enable the individuality of residents to be promoted. Staff training is promoted with a high proportion of staff undertaking NVQ. Documentation must demonstrate a robust recruitment procedure, to ensure the safety of residents. EVIDENCE: There are three care staff including a senior on duty throughout the working day. At the last inspection, a requirement was made to revise staffing levels, in order to enable the individuality of residents to be promoted. No changes have been made although the dependency of residents has been reduced. Ms Robinson confirmed, in her view, ‘staffing levels are not too bad. There is still time to talk to residents or take them in the garden.’ Mrs Robinson explained that she believed senior management to be satisfied with existing arrangements as they comply with their staffing criteria. However, this is not the experience of some residents and their relatives. Within a comment card, one relative stated ‘occasionally I feel XX is overlooked due to changeover of staff/new staff etc. XX won’t ask for help or make a complaint her/himself. I also don’t feel that staff have the time to sit and talk to XX, as I expected they would. Presumably they are overworked.’ Further comments included ‘more staff are needed to give residents the care and attention many need,’ ‘staff wind down a little too soon at the end of the day when patients are going to Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 26 bed’ and ‘needs a call button by the office to locate a member of staff – quite often no one seems to be around.’ One resident commented ‘staff are wonderful but sometimes they forget when they are busy seeing to other clients but they catch up later.’ While acknowledging, staffing levels are maintained as agreed with the previous registration authority, a recent review in relation to residents’ changing needs, has not taken place. The staffing levels remain minimal and if increased, would enable residents’ greater opportunities. This is particularly evident when the home has two waking night staff. This means that there is only one less care staff on duty at night, than in the day. There are also three residents with high dependency needs, who need the assistance of two staff to attend to their personal care needs. This leaves one member of staff to support the remaining residents. There are two domestic staff on duty during the week between the hours of 8am and 4pm. One of the domestics said that they help with breakfast and then clear the dishes away. They then make the dining room ready for lunch and provide residents with fresh drinking water in their bedrooms. After these tasks, they help with the general cleaning. Ms Robinson said the other domestic, spends their whole shift cleaning. At weekends, Ms Robinson confirmed that there is always one member of domestic staff undertaking an 8am to 8pm shift. As stated earlier, there is an activities organiser who works 16 hours a week. Mrs Chapman confirmed that some care staff, also undertake activities. Central laundry, catering and maintenance staff are deployed. Within comment cards, eight residents confirmed that staff listen and act on what they say. One resident said ‘very grateful to be here.’ Within the inspection, one relative stated, ‘the staff are absolutely wonderful. They are genuinely concerned about my XX and I feel he/she is totally safe in their hands. They also care for the relatives. I admire them greatly.’ Specific comments from relatives included ‘I find the staff I come into contact with friendly and helpful’ and ‘all carers have a positive attitude and are always willing to help and support. When time allows they spend time with my XX chatting and listening to him/her.’ Also ‘staff are very attentive and helpful to my XX’ and ‘all the carers have a positive attitude and are willing to help. Support is always given when needed.’ The recruitment documentation of the two most recent members of staff was viewed. One file detailed a job description, which required review. The document instructed the member of staff to be responsible to the staff nurse. The key areas of the post stated ‘to follow a plan of nursing care with the cooperation of residents.’ This file contained an application form that was dated the day after the member of staff commenced employment. There was no evidence of written references or a CRB disclosure. A similar situation was identified at the last inspection. Mrs Chapman explained that the member of staff had transferred from the nursing unit on site. Mrs Chapman believed the Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 27 relevant recruitment documentation had remained on the nursing unit. The second file contained an application form that had been completed, as required. There was no evidence that a reference had been requested from the staff member’s current employer. Mrs Chapman confirmed this had been undertaken. A POVA First check and a CRB disclosure were in place, as required. Staff reported that training is given high priority. They explained there is a standard programme containing mandatory subjects. They could also request specific training, if they felt a need. One member of staff said this occurred with catheter care. Mrs Chapman said the home is currently in the process of changing training providers. The new provider offers an ongoing programme and regular reminders for refresher updates. Mrs Chapman said staff are being put forward for all the training provided by the new provider. This is to ensure all are up to date. During the inspection, Mrs Chapman was identifying participants for risk assessment training. Within documentation sent to CSCI before the inspection, it was stated that all staff either have undertaken or are registered to complete NVQ level 2. A number of staff are undertaking NVQ level 3. Ms Robinson is undertaking level 4. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a supportive management style. Addressing relatives’ views and the implementation of the quality assurance system, will further enhance service provision. Health and safety is given priority yet there is limited evidence of fire safety, which presents potential risks to residents. EVIDENCE: Mrs Chapman has been the manager of the home since May 2006. Mrs Chapman has successfully completed the Registered Manager’s Award and is planning to undertake NVQ level 5. Mrs Chapman has experience of working with older people in residential, day care and domiciliary care settings. Those residents spoken with were clearly aware of Mrs Chapman and her role. A number commented favourably about the changes, which have been made since Mrs Chapman commenced employment. Staff also expressed a positive Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 29 management style that assured openness, motivation, enthusiasm and a feeling of being valued. Staff explained that they now feel more involved and are supported effectively. Within a comment card, one member of staff stated ‘she [Mrs Chapman] has picked the floor up a lot’ and ‘the manager of Alexander Heights really well looks after staff and residents.’ At the last inspection, a requirement was made to develop and implement a quality assurance system. This has been addressed in part. A programme has been devised yet not, as yet implemented. Mrs Chapman reported that a meeting has been arranged with the Fit Person of Care Homes, to discuss its implementation. Questionnaires have been forwarded to residents and their relatives. The feedback from residents has been coordinated. Issues such as improvements requested with food have been addressed with the chef. The relatives’ feedback has not been coordinated. There was no evidence that the feedback had been addressed. Mrs Chapman reported she would address this. Following the inspection, Ms Beeson reported ‘the formal Quality Assurance has already been implemented. The reason Ms Chapman has not completed this document is that she has only recently received back the responses to the inhouse questionnaires she sent out. These questionnaires were being collated and an action plan being formulated just prior to the inspection.’ A number of residents keep small amounts of money in the homes’ safe. The records of all transactions were viewed and two cash amounts were checked. Both amounts corresponded to the balance sheets. Residents or their relatives receive a monthly expenditure sheet, which details all transactions. Receipts to demonstrate expenditures are in place. It was advised that each receipt is numbered and referenced within the balance sheets. This would enable a clearer audit trail. There are a large number of corporate safe working procedures. These include residents’ use of hot water bottles and kettles. It was advised that procedures not within the remit of staff, for example injection administration, are removed. An emergency plan has been coordinated. There were details of recent visits from contractors to service the fire alarm systems. However, weekly checks undertaken by the maintenance person were not available. Mrs Chapman and the staff reported that the checks had been undertaken, as the fire alarm is sounded weekly. This documentation was forwarded to the inspector after the inspection. However, such records must be kept on site and available for inspection. A record of staff fire training is in place yet a number of gaps were evident. Mrs Chapman explained these staff had left employment. This information should be clearly stated. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 30 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 31 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 OP7 Regulation 15 Requirement Care plans must contain specific information to detail the actual support residents require. This must include equipment such as oxygen or a nebuliser. The care plan of the identified resident with a pressure sore must be revised to ensure any further deterioration of their skin is minimised. Care staff must receive training in tissue viability to ensure that they have the knowledge to support those residents who are at risk of developing a pressure sore. The use of bed rails must be authorised by a qualified health care professional. The rails must be monitored and reviewed on a regular basis. Residents must be able to maintain the temperature of their room at a standard acceptable to them. This was identified at the last and subsequent inspection. The operations manager confirmed that progress was being made. DS0000028312.V339169.R01.S.doc Timescale for action 30/11/07 2 OP8 12(1)(a) 21/09/07 3 OP8 18(1)(c) 30/11/07 4 OP8 13(4)(c) 19/09/07 5 OP25 23(2)(p) 31/12/07 Alexander Heights Version 5.2 Page 32 6 OP29 19(1)(a) 7 OP33 24 However, while changes have been made to the radiator valves, residents continue not to be able to independently adjust the temperature. Documentation must evidence a robust recruitment procedure. This must include a sequence of events such as the completion of an application form and medical declaration before commencing employment. A formal quality assurance system must be implemented. This was identified at the last inspection. A system has been devised but has not as yet been implemented. 19/09/07 30/11/07 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 opportunity of purchasing additional support from a domiciliary care agency should be identified within the Statement of Purpose. This was identified at the last inspection but has not been addressed. The daily records should contain aspects contributing to the residents’ quality of life rather than day-to-day physical care tasks. The daily total of food and fluid intake within specific charts should be calculated and monitored to ensure an adequate level. A review of the number of hours available for activity provision should be undertaken. This was identified at the last inspection but has not been addressed. Documentation such as the Statement of Purpose and the Service User’s Guide should give accurate information regarding the provision of social activities within the home. When investigating a complaint, any evidence used should be fully documented. Information should identify whether DS0000028312.V339169.R01.S.doc Version 5.2 Page 33 2 3 4 5 6 OP7 OP8 OP12 OP12 OP16 Alexander Heights 7 8 9 OP27 OP29 OP30 10 OP33 11 OP35 each aspect of the complaint is upheld, not upheld or not substantiated. Staffing levels should be kept under review and be adjusted in relation to residents’ changing needs. A review of job descriptions should be undertaken to ensure they fully relate to the staff member’s role. Training provision should include topics associated with older age such as continence, sensory loss and death and dying. This was identified at the last inspection. Staff reported that they could ask for this type of training. However, such topics were not evidenced within documentation. Feedback received from relatives’ questionnaires, as part of the home’s quality assurance system should be coordinated and displayed. An action plan should be agreed to address the issues raised. Receipts to demonstrate residents’ expenditure of monies held for safe keeping should be numbered, to ensure a clear audit trail. Alexander Heights DS0000028312.V339169.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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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