Inspection on 18/07/06 for Alexander House

This inspection was carried out on 18th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexander House 27/11/08

Alexander House 05/02/07

Alexander House 23/08/05

Alexander House 24/05/05

Alexander House 14/01/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Alexander House 140/142 Folkestone Road Dover Kent CT17 9SP Lead Inspector June Davies Unannounced Inspection 18th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexander House DS0000062424.V293897.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 House DS0000062424.V293897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander House Address 140/142 Folkestone Road Dover Kent CT17 9SP 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) 01304 212949 Nicholas James Care Homes Ltd Mrs Elizabeth Lindsay Care Home 46 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (21) of places Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: Alexander House comprises of two large detached properties interconnected at the rear by a group of three summerhouses. The property is situated in the town of Dover, and is close to all public transport services. The home is registered to provide care for 46 elderly people, to include 21 dementia care beds and three intermediate care beds. The bedrooms in the home are situated on ground floor, first and second floor. The home has five communal lounges plus pleasant sitting areas in the summerhouses. There is a paved courtyard between the two properties and a small-enclosed garden to the rear of the property. Fees are £303.00 to £420.00 Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out over a period of seven hours by June Davies, Regulatory Inspector. The inspector spoke with the assistant manager, seven service users, four staff members and two relatives visiting the home. Documentation pertaining to the standards inspected were also view by the inspector. What the service does well: What has improved since the last inspection? What they could do better: Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 6 Care plans need to be properly completed, reviewed on a monthly basis, and include the service users, to ensure that all needs are met, and that all staff have a good knowledge of the assessed needs of the service users for the delivery of a good quality of care. Service users who spoke with the inspector made comments in relation to care plans like, “No I have not realised that my care plan was reviewed, how often is that supposed to happen,” “I am aware that I have a care plan, because I have heard staff talk about care plans, but I do not know what the care plan is supposed to do.” Referrals to relevant specialists, nutritional screening, and administration of medication all need to improve, to ensure that service users health needs are met. The registered manager must ensure that external grounds are safe for use by the service users, and that access is available without causing unnecessary risks. The level of care staff needs to be monitored on a regular basis, to ensure there are sufficient care staff hours to meet the assessed needs of the service users. Comments from service users regarding staffing levels were, “they are so busy all the time, it is wonderful how they cope,” “they are very rushed, there are so many of us here, and they are always in great demand, it would be nice if they could stop and talk to me sometimes,” “I have to ask the staff for help, they never come to see me to make sure I am O.K.” Staff induction and training needs to be addressed to ensure that there are sufficient trained staff to safely meet the assessed needs of the service users. The management ethos and quality assurance system in the home need to be developed to ensure that the home is providing a high quality service in line with the assessed needs of the service users. 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 House DS0000062424.V293897.R01.S.doc Version 5.2 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 House DS0000062424.V293897.R01.S.doc Version 5.2 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): 1, 2, 3 and 6 Quality in this outcome group is good. The homes statements of purpose and service user guide are good. They provide service users and prospective service users with the information they need to make a decision about moving into the home. Through the statement of terms and conditions/contract each service user is aware of their role and responsibilities in the home. Prospective service users can be confident their needs will be assessed. Step down beds offer good support to clients prior to returning to their own homes. EVIDENCE: Statement of purpose and service user guide has been updated to include dementia care registration, but these documents did not state the number of dementia care beds the home would be providing. A recommendation has been made that these documents are updated to clearly state, the number of dementia care service users in the home. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 9 Each service user is given a statement of terms and conditions/contract. The inspector viewed three statements of terms and conditions/contracts, all stated the number of the room to be occupied, had a breakdown of fees and who would be responsible for paying those fees, and was seen to be signed by the service users and or their representatives. The inspector was able to view three pre-admission assessments for prospective service users, these were seen to give basic information on which to base a care plan, more detailed pre-admission assessments are provided by care managers. The deputy manager stated that new service users are also assessed within the first week of their residence in the home, to ensure all their needs are recognised and entered onto the care plan. Three bedrooms in the home are used as step down beds. These bedrooms are in a dedicated area of the home, and will only be used by clients for a period of eight weeks duration. During their stay the CART team and district nurses will support these clients with occupational therapy. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 10 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, 9 and 10 Quality in this outcome area is poor. The care planning system is not clear and consistent to provide staff with the information they need to meet service users needs. There is very little evidence to show that the health care needs of the service users are met or that there is good multi disciplinary working taking place on a regular basis. The systems for medication administration are only adequate and could potentially place service users at risk. The privacy and dignity of the residents is respected in the home. EVIDENCE: The inspector viewed four care plans, while pre-admission assessments were good; these assessments were not reflected in the care plans. In all care plans, much of the information was missing, pages had not been completed, and there was no evidence of some health care issues being addressed. In one instance a service user who spends most of their time in bed, had no evidence in their care plan of a tissue viability check being carried out, but the service user did have a pressure relieving mattress. Another service user, who has a high level of health needs, had no moving and handling assessment Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 11 completed and no pain assessment. There was no evidence that the service users and or their relatives/representatives had been involved in drawing up the care plan, none of the care plans had been signed. Daily report sheets state ‘all personal care given’, which is not helpful or adequate. No inventories had been completed on any of the care plans viewed. While General Practitioner visits had been recorded, there was no evidence of district nurse, continence nurse, chiropody, optician and dental visits. On three care plans no weights had been recorded. In the case of two service users, cognitive assessments had not been completed, there was a statement that neither could answer the questions, but there was no evidence of any medical or psychiatric assessment for these two service users. Medication policies and procedures were in place, and all staff administering medication had attended medication-training courses. In the office there was a card index with names, signatures and initials of the staff trained to administer medication. On viewed the MAR sheets the inspector found that there were some gaps with no initials entered. In one particular cases a service user had been prescribed an antibiotic for seven days, two days prior to the course of antibiotics finishing there were gaps on the MAR sheet, where the medication had obviously not been given as the course then spanned over a period of nine days rather than seven. Where medication had been prescribed mid month, or a service user had been admitted on respite care, and there were hand written entries on the MAR sheet, this medication had not been recorded onto the MAR sheet correctly, there was no date, no quantity of medication received and no initials of the person signing in. The inspector carried out an audit of medication and found this to be appropriately managed, with medication in bubble packs corresponding with medication administered on the MAR sheets. None of the service users are prescribed controlled drugs. The medication trolleys, and medication rooms were clean and tidy and well ordered. The medication fridge has temperatures recorded on a daily basis. Eye drops prescribed for one service user was not marked on the bottle on the day of opening. All external medication is kept separately from internal medication. Homely remedies given to service users are appropriately recorded on the back of the MAR sheets. The inspector spoke to seven service users all stated that their privacy and dignity is respected by the staff, this was also noted by the inspector during a tour of the home, where staff were seen to be knocking on service users doors before entering. Some of the service users in the home have chosen to have their own telephone in their bedroom. All bedrooms in the home are single. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The overall quality of service is good. Activities and links with the local community are good and meet the service users social needs. Service users are given choice to enable them to remain independent. The meals in this home are good offering both choice and variety and catering for special diets. EVIDENCE: The home employs an activities co-ordinator who works for two hours per day five days per week. Activities in the home consist of bingo, a variety of board games, crosswords, drawing and colouring, and knitting. Service users can choose which activities they take part in. There are occasional trips out of the home, but not many of the service users wish to go on the day of the outing. The home does have the support of three local churches, one church offers Church of England communion, and a Roman Catholic lay worker visits the home to give communion to Roman Catholic service users. One of the service users in the home attends the church of her Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 13 choosing on Sunday mornings. Service users are able to have visitors at any time and this was confirmed by those that the inspector to. Two service users have a power of attorney that manages the service users finances. The other residents have chosen to have their relatives manage their finances for them. The inspector spoke to six service users all said that the meals offered in the home were good, and that they were given sufficient choice to meet their likes and dislikes. The home only caters for diabetic diets at the present time, but the chef confirmed that she would be able to cater for other diets should they be needed. The inspector viewed a four-week rotating menu, and this confirmed that service users have a good choice, and that the home offers a balanced and nutritious menu. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The overall quality of service is good. The home has a satisfactory complaints system with some evidence that service users feel their views are listened to and acted on. Staff have knowledge and understanding of adult protection issues, and whistle blowing which helps to protect the service users from abuse. EVIDENCE: The home has had not complaints since the last inspection. The complaints policies and procedures have been reviewed in the last year and are included in the statement of purpose and service user guide. The service users in the home told the inspector that they knew how to make a complaint and whom they would make the complaint to. Policies and procedures for the protection of the service users, and whistle blowing have all been reviewed in the last year. There have been no incidents of abuse in the home. The home also have reviewed policies and procedures in place, which preclude care staff from having any dealings with service users personal finances or receiving bequests from service users. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 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): 19, 20, 21, 24 and 26 Quality in this outcome group is adequate. The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: The location of the home is suitable for its stated purpose. The home is well decorated and maintained, and has an ongoing programme of maintenance, and renewal. The inspector did have some concerns regarding the double gates used to close the courtyard area off, were open on the day of the visit and cars were parked in the courtyard. Some of the service users were using this courtyard area, which could put them at risk of reversing cars, and they also had access to a busy major road. The courtyard is a pleasant area in which service users can sit, with garden furniture, sun umbrellas, and planted pots. One of the service users has chosen to grow some tomatoes in pots in the courtyard, and these looked well tended and cared for. The small garden Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 16 to the rear of the property was rather untidy, with dead leaves and twigs and little attention paid to the flower borders in this area. The communal lounges were well decorated and domestically furnished, and service users are able to have a choice of sitting in a television lounge or a quiet lounge. During the visit the inspector noted that workmen were working in one of the two dining rooms, and it was explained that this dining room was being made smaller to accommodate a coffee and tea making area for the service users. To make this dining room smaller would not provide sufficient dining space for all the service users. At the present time four the service users eat their meal in their bedrooms (service users choice), and the home offers day care to two clients who have to eat their meals in one of the communal lounges. Care staff also stated that the dining room gets very overcrowded with service users Zimmer frames, and this poses a risk to staff and service users at mealtimes. The inspector carried out a tour of the home, and found communal toilets and bathrooms to be clean and tidy and free from offensive odours. Pedal bins, paper hand towels were available throughout, but it was noted that liquid soap was missing from some toilets and bathrooms. Service users bedrooms were seen by the inspector to be well decorated, sufficiently and domestically furnished, and had been provided with a lockable space. All bedrooms had been personalised by the service users. Each bedroom door has been fitted with a lock and service users have a key unless they wish not to. The whole home is free from offensive odours. The laundry room is sited away from the kitchen area. The laundry has industrial washing machines, with sluicing and disinfecting programmes and commercial tumble driers, the laundry room floor is impermeable. On the day of the visit the laundry room was clean, tidy and well ordered. All staff are provided with protective gloves and aprons to prevent cross infection. Clinical waste was seen by the inspector to be disposed of in an appropriately coloured bag, and then into a clinical waste container. The hand washing facilities in the home displayed universal hand washing instructions. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 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, 28, 29 and 30 Quality in this outcome group is poor. Staffing levels, job related training, and mandatory training are low which has a detrimental impact on the consistency of care offered to the service users. Recruitment practices have improved, but further progress needs to be made to ensure that service users are not at risk of abuse. The arrangements for the induction of staff are poor leaving staff without a clear understanding of their roles. EVIDENCE: From information supplied regarding dependency levels of Service Users in the pre-inspection questionnaire, and evidence from duty rotas on the day the visit, the care staffing hours are below the minimum hours recommended by the Residential Forum guidelines. Care staff spoke of the frustration of not having time to sit and talk with the service users in the home, and some service users commented on how busy the staff were and what a demand there was on their time. Evidence available from the staff training matrix only 33 of the care staff have NVQ level 2 or above. A further six care staff should complete their NVQ level 2 at the end of July 2006. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 18 The inspector looked at five staff personnel files; all but one file had relevant documents in place, which included application forms, two written references, and two forms of identification and CRB checks. One member of staff who is a long-term employee did not have the required documentation on file or a CRB check, and a requirement has been made that this is applied for. The registered manager must ensure that a full employment history is obtained for all new staff, and that interview evidence is recorded. The training matrix showed that 66 of care staff have received first aid training, 80 of care staff have food hygiene training, 33 of care staff have fire safety training and 60 of care staff have received POVA training. There was no evidence of any care staff completed infection control training. All staff have recently completed a home study course on dementia care. All staff have received health and safety induction, carried out over one day, but none of the staff have completed Skills for Care induction training. The company has just compiled an induction pack, which is related to Skills for Care induction and this should be introduced to new employees in the future. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 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, 32, 33, 35, 36 and 38 Quality in this outcome group is poor The management of this home is satisfactory, but overall with little evidence that service user, relative/visitor, staff and outside stakeholders views are sought EVIDENCE: The registered manager does not have NVQ level 4 or RMA but does have many years experience of managing in a residential care setting. She has recently completed a dementia care training, nutrition and food hygiene training. The registered manager is also aware of the diseases related to old age. Nicholas James Care Homes Ltd. now owns the home, and there are clear lines of accountability throughout the organisation. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 20 The inspector was able to talk with four members of staff, six service users and two relatives during the course of the visit. Some of these conversations suggested that the manager was not always approachable. Some service users stated that if they needed to make a complaint they would approach the assistant manager, one relative stated that they would prefer to approach the assistant manager if they had any concerns, and some staff said that they found the assistant manager more helpful. The assistant manager confirmed that the home has regular staff meetings, and evidence was available to show these meetings are recorded. The registered manager has a copy of the code of practice published by the General Social Care Council, and all new staff are given a copy of the code practice. The home does not have a quality assurance monitoring system in place and the inspector has therefore made a requirement that the home starts to use a good quality assurance system, that would include feedback from S.U’s, relatives/friends, and external stakeholders. The quality assurance system must also include regular auditing of medication, care plans, risk assessments of building both internal and external, standard of cleanliness, quality of food and meals, standard of care and regular auditing of S.U.’s personal monies kept in safe keeping by the home. The home does keep some of the S.U.’s personal monies for safekeeping. Each S.U. has their own finance sheet, and individual envelopes together with any receipts for expenditure; both monies and records are kept in a secure place in the home. The registered manager does not act as an agent for any of the S.U.’s in the home. Staff confirmed that they receive regular supervision sessions on a two monthly basis and written evidence of supervision taking place was available on staff personnel files. Not all staff have completed mandatory training. Maintenance certificates were seen by the inspector to be up to date for the following equipment in the home, boilers, electrical circuit testing, electrical portable appliances, lifts, hoists, fire panel, fire alarms, and fire fighting equipment. Water delivery from hot water taps throughout the home is at 43ºC. All windows are fitted with window restrictors. Health and safety policies and procedures have been reviewed in the last year. An internal risk assessment has been carried out, but this must be carried out on a regular basis. Two HSE accident books were seen by the inspector one for staff accidents and another for service user accidents, all accident forms had been accurately recorded, and had been filed separately from the accident book. While staff do receive health and safety induction training, this was seen to be completed in one day, and a recommendation is being made that health and safety induction takes place over a period of six weeks, to ensure that new staff have a thorough understanding of health and safety procedures in the home. Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 21 Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 3 X 3 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 3 X 2 Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 Schedule 3(1)(b)(3) (a)(b)(d) 15(2)(b) (c)(d) Schedule 3(1)(b) Requirement The service user’s health, personal and social care needs are set out in an individual plan of care. The service user’s plan is reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care and actioned. He plan is drawn up with the involvement of the service user, recorded in a style accessible to the service user; agreed and signed by the service user whenever capable and/or their relative/representative. Care staff maintain the personal hygiene of each service user and wherever possible support the service users own capacity for self care. ‘All care given’ is not helpful or adequate (Previous requirement - timescale of 11/02/05, 25/05/05 and 24/08/05 not met). The service user’s physical and psychological health is monitored DS0000062424.V293897.R01.S.doc Timescale for action 02/10/06 2. OP7 02/10/06 3. OP7 15(1)(2)( a)(c)(d) Schedule 3(1)(b) 11/09/06 4. OP8 12(1) 11/09/06 5. OP8 13(1)(b) 02/10/06 Alexander House Version 5.2 Page 24 6. OP8 14(1)(a) (2) 17(1)(a) Schedule 3(3)(m) 13(2)(4) (c) 7. OP9 8. OP19 13(4) 23(2)(o) 23(2)(e)(i) 18(1)(a) 9. 10. OP20 OP27 11. OP28 18(1)(a)(c) 12. OP29 19(b) Schedule 2(2)(a) 13 OP30 12(1)(a) (b) Regularly and preventative and 11/09/06restorative care provided. Nutritional screening is undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss, and appropriate action taken. The registered person ensures that there is a policy and staff adhere to procedures, for the receipt, recording, storage, handling, and administration of medication. Grounds are kept tidy, safe, attractive and accessible to service users, and allow access to sunlight. Communal space is available which includes sufficient dining space for ALL service users. The ratios of care staff to service users must be determined according to the assessed needs of the service users, and a system operated for calculating staff numbers required, in accordance with guidance recommended by the Department of Health A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved by 2005, excluding the registered manager. The registered person shall not employ a person to work at the care home unless she has obtained in respect of that person the information and documents specified in paragraphs 1-9 of Schedule 2. The registered person ensure that there is mandatory training for all staff to include first aid, manual handling, fire safety, food hygiene, infection control DS0000062424.V293897.R01.S.doc 11/09/06 11/09/06 11/09/06 02/10/06 02/10/06 04/12/06 11/09/06 02/10/06 Alexander House Version 5.2 Page 25 14. OP30 12(1)(a) (b) 18(1)(a) (c) 15. 16. OP32 OP33 12(1)-(5) 24(1)(a) (b), (2)(3) and POVA (Previous requirement made and not met from 24/08/05 The registered person ensures that all members of staff receives induction training to NTO specification within 6 weeks of appointment to their post, including training on the principles of care, safe work practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. (Previous requirement made and not met from 24/08/05) The process of managing and running the home are open and transparent. The registered persona shall establish and maintain a system for evaluating the quality of the services provided at the care home. 02/10/06 11/09/06 04/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP26 OP38 Good Practice Recommendations Statement of purpose and service user guide to be updated to state number of dementia care places in accordance with the registration certificate. All communal hand-washing facilities are supplied with liquid soap. All staff receive induction and foundation training and updates to meet Skills for Care specification on all safe working practice topics within the first six weeks of their employment. Care should be taken to ensure that this induction is not fitted into one day. DS0000062424.V293897.R01.S.doc Version 5.2 Page 26 Alexander House Alexander House DS0000062424.V293897.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 House DS0000062424.V293897.R01.S.doc Version 5.2 Page 28 - 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. 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