Inspection on 06/12/05 for Alexander Heights

This inspection was carried out on 6th December 2005.

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 05/09/07

Alexander Heights 21/09/06

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 6th December 2005 09:40 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.V269961.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 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 Vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: Alexander Heights is a residential care home registered to care for 28 older people. Nursing or 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 air conditioned conservatory style lounge. Residents also have access 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 and a games room. 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. The complex provides central catering, laundry and maintenance staff. At night there are two waking night staff. The home has recently appointed a new manager, Mrs Clare Ghey. Mrs Ghey has experience of working with adults within residential settings and is currently undertaking the process to become the Registered Manager. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of approximately seven hours on the 6th December 2005. There were three carers on duty at the start of the inspection and discussion took place regarding general matters within the home. Mrs Clare Ghey arrived at 10am to commence her shift and assisted the inspector throughout the day. Mrs Lisa Beeson, general manager also arrived at 10am in order to introduce the new manager. A tour of the home was made and the inspector spent time with residents in their private accommodation. Care planning information, daily records and the fire log book were viewed and discussion took place regarding training and quality assurance systems. Feedback regarding the service was generally positive although some negativity about the food was evident. Various issues had been discussed with the manager and those residents concerned, felt listened to and confident that their complaints would be addressed. All residents commented favourably about the staff and their private accommodation. Other factors were the ability to follow preferred routines, recently developed activities and the opportunities to develop friendships. What the service does well: What has improved since the last inspection? The deployment of an activities organiser has enabled the development of a structured programme of in house activity. The deployment of housekeeping staff at weekends has given care staff greater time to concentrate on care provision. It has also enabled a higher standard of cleanliness within the home. Additional assessments have been added to care planning information, yet the proposed introduction of the new format appears much improved. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 While residents are assessed before admission, written documentation is limited and does not give sufficient detail to meet individual need. EVIDENCE: Due to the format of the site, many prospective residents are known to the home. This was reported to aid the settling in period by enabling the continuation of social interests and the company of friends. Since the last inspection there have been a number of new admissions. Discussions evidenced satisfaction with the service received. A number of written assessments were also viewed. It was noted that although a visit to the individual’s own surroundings had taken place, written information was extremely limited. Documentation contained some very basic information, yet an accurate reflection of need was not available. It was therefore not possible to determine individual requirements or in fact whether they could be met within the home. Alexander Heights does not provide intermediate care. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 All residents have an up to date care plan, yet the identified new format, which is to be implemented soon, appears much improved. Residents’ health care is well managed with regular contact with professionals such as GPs and Community Nurses. Residents feel that a caring staff group promote privacy and dignity within care provision. EVIDENCE: Each resident has a plan of care that contains basis information. All are up to date and since the last inspection, assessments such as pressure care management have been addressed. During discussion with Mrs Ghey, it was evident that a new care planning format is being introduced. Mrs Ghey felt the new format would address residents as a whole while taking into account social matters and individual wishes and preferences. The plan would give priority to all needs rather than just concentrating on physical matters. Mrs Ghey reported that she hoped to have the new format in operation by Christmas. This would involve individual discussion with residents while emphasising the Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 10 importance of their involvement. Mrs Ghey is hoping that staff will also be able to contribute to the content of the plans through staff meetings. There are GPs and Community Nurses on site and therefore regular contact is maintained. Both visit on set days and can also be called when required. Consistency is therefore achieved although residents are somewhat restricted from maintaining or choosing their own GP. It was reported that all other health care services, such as chiropody, provide domiciliary visits. Referrals are made for specialist services and out patients appointments are attended as required. Due to such regular contact with health care professionals, emphasis is given to prevention. Regular health care and medication reviews are undertaken and conditions can be monitored efficiently. Residents reported that all staff are excellent and offer help in a caring manner. All felt their privacy and dignity were respected. This included care provision taking place in the privacy of private accommodation or bathrooms as appropriate. Residents are able to meet with their visitors where they wish and many have a personal telephone in their room. Staff were seen to knock on doors and address residents in an individual, preferred manner. Some residents reciprocated appropriate banter demonstrating productive relationships. At the last inspection it was identified a gender working policy was required. Mrs Ghey reported that she was not aware that this had been addressed although chosen care provision is now identified within individual plans. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 The appointment of an activities organiser has enabled a structured programme of activities, which is based on individual interest and preference. Some residents would benefit from the development of further external activity. Residents are encouraged to follow their preferred routines and spend their time as they wish. Although a variety of food is offered, some residents have a number of issues to be resolved before full satisfaction is reported. EVIDENCE: At the last inspection social activity within the home appeared limited. Some residents reported that days seemed long and boredom was a challenge. With staffing levels maintained at the minimum, opportunities to facilitate social activity was limited. A requirement was therefore made to ensure that staffing levels enable residents to be involved in meaningful activity in relation to their wishes. In response to this, an activities organiser has been deployed. There is now a programme of planned activities and all residents are given written details of opportunities on a weekly basis. Activities are based on residents’ preferences although the programme can be relatively flexible. This Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 12 appointment was reported to be a tremendous benefit to the home. Residents also appreciated being informed of events in advance. Mrs Ghey reported that while much improved, she would like to heighten the profile of the home and encourage greater external activity. This would include greater use of the organisation’s transport. A number of residents reported enjoyment when going out with relatives and therefore it is hoped that the development of external events will be successful. Residents are encouraged to follow their preferred routines and choose how to they spend their time. All are encouraged to manage their financial affairs if they are able. Many have chosen to keep a small amount of money within the home for safekeeping. This is managed with a detailed record of transactions and receipts to demonstrate expenditures. Residents are encouraged to bring items of furniture with them on admission and make their private accommodation as homely as possible. Mrs Ghey reported that she believed all residents knew that they had a personal file and staff recorded information about them. She was not sure however if residents were aware that they had access to their files. Mrs Ghey reported she would discuss this when completing the forthcoming introduction of the new care-planning documentation. Catering arrangements were not assessed on this occasion although at the last inspection some residents raised issues with the food and meal arrangements. Mrs Ghey has met with a number of residents and their concerns have been reported to the chef in writing. It is anticipated that a meeting with residents, Mrs Ghey, and the catering staff will be arranged although to date this has not taken place. At the last inspection, the length of the meal was raised as an issue. Through observation, it was evident that there had been little change. Some residents also spoke of cold food due to the lengthy serving process. Mrs Ghey reported that she was aware of this and had given the matter consideration. Solutions to rectify the problem however were limited due to environmental issues. At the last inspection, limited space within the dining room was a problem. In order to address this, staff were planning to use the games room as an eating area. It was not evident whether this was tried although limited space was not raised as an issue on this occasion. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaint information is readily accessible and residents feel able to raise their concerns. Re-visiting adult protection procedures with staff would give residents greater protection. EVIDENCE: The complaint procedure was not viewed on this occasion although was noted to contain the required information at the last inspection. Residents reported that they would and some had, spoken to staff about unsatisfactory issues. A number of residents spoke of concerns about the food. They were pleased that the new manager had taken them seriously and had raised the issues with the chef. Residents felt they had been listened to and were confident that issues would be addressed. Mrs Ghey reported that she aims to develop consultation and therefore residents meetings and individual one–to-one time will be given priority. Mrs Ghey also encourages an open approach and residents are encouraged to meet with Mr Ghey informally in the office for a chat at any time. Mrs Ghey reported that ‘No Secrets’ documentation is available within the home although the full Wiltshire and Swindon Vulnerable Adults procedure has not as yet been located. It was therefore recommended to request an additional copy. It was reported that the previous manager gave all staff their own individual copy of the ‘No Secrets’ documentation. As Mrs Ghey is new in post a recommendation was made to repeat this process in order to ensure all staff have and are familiar with the procedure. A number of staff have Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 14 undertaken adult protection training although Mrs Ghey is planning to extend this to all staff in the New Year. As stated earlier in this report, a requirement was made at the last inspection to develop a gender working policy. Mrs Ghey believes that this remains outstanding and therefore the requirement is repeated. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 25 The home is furnished to a good standard and residents are able to personalise their rooms. Immediate attention is required to minimise the risks of residents suffering an injury from hot water. Although bearable on this inspection attention must be given to the ventilation of the home before the onset of the better weather next year. EVIDENCE: A tour of the accommodation was made and all areas were noted to be clean, odour free and well maintained. All private accommodation is personalised according to individual wishes with the opportunity of containing residents’ own furniture as required. Residents are able to have their own telephone and all have access to a call bell. Rooms have en-suite facilities and are also within close proximity of assisted bathing facilities. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 16 At the last inspection the home was very hot and ventilation was very poor. This was particularly so in the corridors and the small kitchenette. Air conditioning units had been used in the corridors although these had to be removed on the instruction of the Fire Officer. Fans were in place although totally insufficient and both residents and staff were struggling with the atmosphere. On this occasion, due to the time of the year, the atmosphere was better. Staff and residents however reported an ongoing problem and described some days as unbearable. A requirement was made to give consideration to improving the heat and poor ventilation within the home with particular attention to the kitchenette and corridor. Mrs Ghey did not believe that this had been addressed although quotes for air conditioning had been sought. This requirement is therefore repeated. At the last inspection due to the heat in the small kitchenette, the fire door was being propped open to incorporate the air conditioning of the lounge. A requirement was therefore made to address this matter. On this occasion the door was closed yet there was no need for the air conditioning. This matter must therefore be addressed before the warmer weather next year. All radiators have been fitted with covers although temperature controls have been covered up within. At the last inspection a requirement was made to ensure all residents were able to control the temperature of their room as a number of negative comments were received about being too hot. At the beginning of the inspection, Mrs Beeson reported that work is planned to enable residents to have access to the controls although a date has not been decided upon. The requirement is therefore repeated. Hot water temperatures are regularly monitored and documented accordingly. It was noted however that hot water from the hand washbasin in a resident’s room was recorded as 61°C. This had been recorded over a number of months although had not been rectified. An immediate requirement was therefore made to address such. A number of other outlets were higher than recommended and a few, although not fitted with a regulator, had not been tested. Mrs Ghey was informed of the need to ensure staff randomly test all outlets and interpret the recorded temperatures by appropriately addressing any areas of risk. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staffing levels continue to be maintained at a minimum, yet the new appointment of an activities organiser and weekend housekeeping staff have aided the situation. Training information needs to be organised before shortfalls in training provision can be identified and therefore rectified. EVIDENCE: Staffing levels continue to be maintained at three members of care staff on duty throughout the waking day. At night there are two waking night staff. Domestic staff support the team during the day and since the last inspection domestic staff have been deployed at weekends. The home has a newly appointed activities organiser and catering and laundry staff are deployed centrally. At the last inspection, the home was very busy. Residents had to wait and there was insufficient time to undertake social activities. While residents continue to report that staff are very busy, the appointment of an activities organiser has helped the situation. Mrs Ghey reported that additional shifts required to cover the home are being highlighted and therefore monitored. Mrs Ghey confirmed that these were minimal and at present the workload appeared acceptable to meet residents’ needs. At the last inspection the manager was advised to monitor manual handling practise as despite having received training, an inappropriate technique was noted. Mrs Ghey was unsure if this had been addressed and therefore reported she would reorganise a session for all staff to attend. Further discussion took Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 18 place regarding training and within the inspection, Mrs Ghey aimed to investigate the training staff had undertaken. Unfortunately due to training records not being up to date it was difficult to ascertain such. It was agreed that a requirement would be made to reorganise all training material and address any shortfalls identified. Training would then be assessed at the next inspection. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The home has a new manager, who is experienced and has a sound value base. Quality auditing systems are not clear at this time, yet the implementation of such with emphasis on residents’ involvement is being investigated. Greater attention and clarity must be given to fire safety measures in order to ensure the safety of residents. EVIDENCE: As stated earlier in this report, Mrs Ghey began her post on the 3rd October 2005. Mrs Ghey is currently applying to become the registered manager although the process is in its early stages. Mrs Ghey’s previous position was a Service Co-ordinator with an organisation providing care provision to adults with a learning disability. Mrs Ghey therefore has managerial experience and knowledge of residential settings. Through discussion it was evident that Mrs Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 20 Ghey has a sound value base and aims to comprehensively meet residents’ needs through a holistic approach. The above standard regarding the manager has been given a standard met score of 2, as Mrs Ghey has not as yet completed the process to become the Registered Manager. Discussion took place regarding quality assurance and Mrs Ghey reported that she was not sure whether the home had a formal, established system. While beginning to become familiar with the home’s systems, documentation linked to quality auditing had not been found. Mrs Ghey was therefore planning to request information from line management within the organisation. In the meantime informal discussion with residents is held and meetings are planned. As stated earlier in this report, all residents are encouraged to manage their own financial affairs. The home is not involved in this area. A number of residents however have chosen to place a small amount of money in the safe for safekeeping. A number of balance sheets were viewed and all were appropriately maintained. It was not possible however to check the cash against the balance sheets as Mrs Ghey did not have the keys. Money held for safekeeping will therefore be checked again at the next inspection. Health and safety was not assessed in great detail at this inspection. Through discussion however it was evident that the fire panel in the office was not clearly understood. A floor plan was also unavailable and the fire procedure of assembling downstairs would loose staff valuable time. Mrs Ghey was therefore informed of the need to review these matters and ensure all staff could detect the whereabouts of the fire by using the panel in the office. Within the inspection, staff had difficulty locating the fire log book as it had been taken to another part of the complex. Documentation demonstrated satisfactory testing of the fire safety systems although a recent fire drill was not evident. Mrs Ghey reported that she had only just realised that fire drills were her responsibility as the maintenance staff undertake all other testing. Mrs Ghey therefore confirmed a drill would take place as a matter of urgency. Within documentation it was evident that not all staff had fire instruction during the July/September period. Recent copies demonstrating the servicing of the systems by external contractors were also not available. Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X 3 1 X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The Registered Person must ensure that a full assessment is undertaken before admission. This must be documented accordingly with sufficient detail to enable individual needs to be met. The Registered Person must ensure that a policy regarding gender working is developed. Timescale for action 06/12/05 2. OP10 12(1)(a) 28/02/06 3 OP25 23(2)(p) This was identified at the last inspection and the timescale of 31/08/05 was not met. A revised timescale has therefore been identified. The Registered Person must 31/03/06 ensure that consideration is given to improve the heat and poor ventilation within the home. Particular attention must be given to the kitchenette and corridor. This was identified at the last inspection and has not been addressed. The Registered Person must ensure that residents are able to DS0000028312.V269961.R01.S.doc 4 OP25 23(2)(p) 31/03/06 Alexander Heights Version 5.0 Page 23 maintain the temperature of their room at a standard acceptable to them. This was identified at the last inspection and has not been addressed. The Registered Person must ensure that immediate attention is given to minimising the risk of injury from the hot water outlet in the identified bedroom. The Registered Person must ensure that all hot water outlets are monitored and any high or unpredictable temperatures are addressed accordingly. The Registered Person must ensure that all training documentation is reviewed and any identified shortfalls are addressed. The Registered Person must ensure that a formal quality assurance system is implemented, with residents’ views as an integral part. The Registered Person must ensure that the fire panel in the office is understood and the fire procedure is clarified to ensure valuable time is not lost in the event of fire. The Registered Person must ensure that all staff have fire instruction and a fire drill takes place within each identified period. This must be fully documented within the fire log book. 5. OP25 13(4)(a) (c) 06/12/05 6. OP25 13(4)(a) (c) 06/12/05 7. OP30 18(1)(c) (i) 28/02/06 8. OP33 24 28/02/05 9. OP38 23(4)(c) (iii) 31/12/05 10. OP38 23(4)(e) 31/12/05 Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 24 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 OP15 Good Practice Recommendations The Registered Person should give consideration to how mealtimes can meet the needs of all residents. Matters such as the length of time the meal takes to serve should be taken into account. This was identified at the last inspection. The Registered Person should ensure that a copy of the Wiltshire and Swindon Vulnerable Adults protocol is readily accessible within the home. The Registered Person should ensure that all staff have a new copy of the ‘No Secrets’ documentation and confirm their receipt of such. The Registered Person should monitor manual handling practices and give additional training as required. This was identified at the last inspection. The Registered Person should ensure that there is a floor plan of the home available in the event of a fire. The Registered Person should ensure that documentation demonstrating the servicing of the fire safety systems is maintained in the fire log book. 2. 3. 4. OP18 OP18 OP30 5. 6. OP38 OP38 Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexander Heights DS0000028312.V269961.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!