Inspection on 25/07/06 for Alexander Residential Home

This inspection was carried out on 25th 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 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 Residential Home 01/05/07

Alexander Residential Home 22/11/05

Alexander Residential Home 01/12/04

Alexander Residential Home 27/07/04

Alexander Residential Home 23/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Snydale Care Home

Muston Road (70)

Abbey The

Grayling

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

CARE HOMES FOR OLDER PEOPLE Alexander Residential Home Victoria Road Morley Leeds West Yorkshire LS27 9JJ Lead Inspector Susan Knox Key Unannounced Inspection 25th July 2006 08:30 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 Residential Home DS0000001409.V301649.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 Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander Residential Home Address Victoria Road Morley Leeds West Yorkshire LS27 9JJ 0113 253 2046 0113 2527732 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Peter Morris Mrs Margaret Morris Care Home 32 Category(ies) of Dementia - over 65 years of age (10), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (32) Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the category LD(E) be used for the individual named on the accompanying notice. 22nd November 2005 Date of last inspection Brief Description of the Service: Alexander residential home is a large detached building, with an extension called the ‘Cottage’ to the rear. The home provides residential care and accommodation for 32 older people including a number with dementia. It is located to the south of the city of Leeds. The building has a number of facilities suitable for older people, including a passenger lift. There are a several lounge areas, which are located on both floors of the home. A number of bedrooms have an en-suite WC and there is one shared bedroom. The home is reasonably close to a range of suitable local amenities, including shops and pubs and has good access to public transport; a bus stop is located at the entrance. Car parking facilities are available close to the building. There is a large garden to the front and side of the property; this is not easily accessible to older people. There are plans to utilise this by providing a decking area to the front and enclosing the side garden. Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has an acting manager who was the former registered manager. Mrs Everad terminated her employment in September 2005 and returned in January 2006 She has submitted a manager application to the CSCI. A pre inspection questionnaire was sent to the manager to be completed with up to date information about the home in time for the inspection. This had been returned to the CSCI in time for the inspection. Comment cards were sent to two visiting professionals before the inspection. Two were returned with positive responses in time for this report. One inspector carried out this unannounced key inspection between 08.30am and 4.45pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. During the inspection the inspector spoke to four residents individually and groups of others in two lounges, five staff and the acting manager. Some parts of the building were checked. Records were inspected including care plans, assessments, staff recruitment and training records and health and safety records. The acting manager had recently conducted her own survey by sending out comment cards to residents and relatives. A number of these were available for inspection therefore the CSCI cards were not left to be distributed. During the visit observations of morning routines including breakfast time showed that staff were observant of resident’s needs and safety, provided them with choice and respected their privacy. What the service does well: Residents said that staff care was very good. They also said that the meals were very good. Pre admission assessments are carried out before moving to the home to ensure that resident’s needs can be met. Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 6 The manager promotes on going staff training so that individual needs can be met. Staffing levels are increased as required so that resident’s needs can be met. A very homely environment is provided for service users. Residents are provided with positive choice of meals and daily routines. Staff said that service users are looked after very well and the standards of care are very high. What has improved since the last inspection? 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 Residential Home DS0000001409.V301649.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 Residential Home DS0000001409.V301649.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. Quality in this outcome area is good. This judgement has been made following a site visit and by checking records. The Statement of Purpose/Service User Guide provides sufficient information so that existing and prospective residents are kept fully informed of the service. The manager does ensure residents are fully assessed prior to admission and that staff can meet their needs. Copies of contracts of residency must be available for inspection. EVIDENCE: Since the last inspection there has been a variation in registration so that the home can provide care for up to ten residents with dementia. An amended statement of purpose was submitted to the CSCI as part of this process. The acting manager confirmed that the Service User guide is given to prospective residents and/or relatives. This provides information about the home. The Statement of Purpose is usually displayed in the home for visitors to see but had been taken by a resident. No contracts of residency were seen in the care documentation for the three residents case-tracked. The manager said that these are at the provider’s Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 9 second home in Bury. These records have to be available for inspection at all times. In the care documentation for the service user’s case tracked there was evidence that two had been assessed before admission. One had been admitted before the manager had returned to her post and there was no pre admission assessment. The manager confirmed that that either herself or assistant manager undertakes these visits. Through case tracking the most recent admissions, talking to staff and observing routines it was clear there was an understanding of individual needs. There was evidence in training files that care staff have received training, the most recent was about dementia. Alexander Residential Home DS0000001409.V301649.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, 10. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. The care-planning format has improved but all individual needs must be included. The procedures for administering medication are good. EVIDENCE: The inspector chose three residents to case track. Care plans were in place for all three and addressed individual needs. Risk assessments such as moving and handling were in place and up to date. In one set of care documentation it was apparent that behaviour of one resident was giving concern. This was not addressed in a care plan. The new assessments for those with dementia include strength assessment and risks. Relatives had been involved in establishing life histories and information relating to young adulthood, middle age and later years. This gave staff very good details about the life of one individual and the names of people familiar to the resident. From discussions with staff and the documentation it was clear that the health needs of residents were being met. The multi disciplinary records showed the different professionals who are contacted for advice and support with the care of individuals. For example, on the day of the inspection the manager was Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 11 escorting two residents to different appointments with health care professionals. Two comment cards were returned form health professionals both had positive responses to the questionnaire. The medication records and storage were checked. A monitored dosage system (MDS) is in place. Two drug trolleys are in use and taken to the different floors in order to dispense medication. A locked storage room is available for storing the trolleys when not in use. Policies and procedures were available in the drug room and in the office. The recording of the administration of medication was satisfactory. Stock control checks can be carried out as the amount of tablets brought into the home is recorded. Three resident’s medication was checked including controlled drugs and antibiotics. The number of tablets was correct and tallied with the administration record. One resident was able to say she was happy with the way medication was administered. Staff confirmed that they had had medication training and this was verified in the training records and certificates. From observations carried out during the visit staff were caring. Interaction between residents and staff was good. Residents looked well cared for. Residents were treated with respect and privacy was provided. One care plan showed that the resident did not want her relative to be involved and staff respected this. Staff were seen to knock on bedroom doors and other doors were shut for privacy as necessary. Residents confirmed that staff respected their privacy and treated them in a dignified way. Alexander Residential Home DS0000001409.V301649.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, 15. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. Activities ensure that the residents receive some stimulation and a focus to parts of the day. Staff welcome visitors who call at the home. The residents enjoy the meals and are offered choice. EVIDENCE: There was evidence on display about attempts to involve residents and keep them orientated. The daily board gave information about the date and the weather. A list was in the office giving the dates when a local church visits to give communion. Photographs of residents were displayed. Due to illness the activity coordinator has not been able to work in this role. However, staff confirmed that they organise exercise to music. Activity records showed evidence of in door activities such as skittles and bingo. A resident confirmed this. There are plans to hold a garden party, visit a local fish restaurant and a coach trip. Recently there has been a visit to Batley Variety Club. One visitor was happy with the progress of her relative and in particular how she was encouraged to take part in activities. The manager has recognised that evening time can become a concern due to some residents requiring more one to one attention from staff. In order to Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 13 address this additional staff are on duty and will focus for example, on those who would benefit from a walk around the garden. The home receives many visitors; on the day of inspection one confirmed that staff were welcoming. The quality assurance forms returned to the manager and thank you notes from relatives showed evidence of good relationships with staff. From observations and discussions it was apparent that staff attempt to provide choice. They enable residents to retain control of daily living while at the same time recognising where they may be at risk. Some residents were still in bed at the time of arrival at the home. Staff confirmed that bedtimes were entirely the resident’s choice. Staff were overheard giving positive choices during the mealtime and additional helpings and drinks were given on request. Menus were displayed in the home. A definite choice is available at all mealtimes. Residents spoke well about the food and one said a balanced diet was provided. The cook confirmed that special diets are catered for and individual needs met, examples were given. The manager and cook have recently attended a course about nutrition and dementia. This was said to be very informative. Alexander Residential Home DS0000001409.V301649.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, 18. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. An appropriate complaint’s procedure is in place. Service users are safeguarded as staff are trained in how to deal with allegations of abuse. EVIDENCE: The homes complaint procedure was displayed in the home readily available for visitors to see. The procedure is also in the Statement of Purpose/Service User guide. The manager is aware that complaints have to be recorded with a report of the action taken to address the complaint. The CSCI have received no complaints about the home and the manager said none have been made to her. The returned quality assurance questionnaires raised one or two issues. The manager confirmed that she had taken steps to address these. Some residents were able to confirm that they would speak to staff if they had any concerns. Staff confirmed that they had attended training in abuse and adult protection. This was also evident in the staff training records. During discussions it was evident that staff would react robustly to any allegations of abuse. Alexander Residential Home DS0000001409.V301649.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): 19-22, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence from the site visit that included an inspection of some bedrooms and communal areas. There is a good understanding of infection control procedures. The home provides a homely, clean and very comfortable environment however some outstanding building issues must be addressed. The garden must be made easier to access and more secure. EVIDENCE: This home provides care for residential service users some with dementia. External decoration has taken place to good effect since the last inspection. There is level access into the home via a ramp to the main door. There is nearby parking for visitors. The large garden is not easily accessible. The provider has plans to provide decking to the front and discussions were held about making the side garden easier to access and more secure. There is a passenger lift and a stair lift. The bathrooms and WC’s are fitted with hoists, handgrips and high seats. There are a number of hoists to use if Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 16 necessary. This includes a newly purchased standing hoist with turntable that was said to be very effective. Communal rooms are located on all floors. They were well-furnished and provided comfortable seating. Continence aids are discreet. The former activity lounge has been decorated and provided with café type tables and chairs. The manager and staff are trying to promote more use of this little used room. The home has accounted for the impact of the environment on those with dementia in some ways. The WC doors have been painted different colours so that they stand out to someone who may be looking for the facility. One bedroom door was clearly labelled with the resident’s first name and a photograph. However, improvement could be further enhanced if patterned carpets were replaced with plain. Some residents with dementia find patterned carpets difficult. The home has progressed well since the last inspection with redecoration and new carpets in some bedrooms. Still outstanding and it has been for some time is the completion of the work to upgrade the bathroom in the ‘cottage’ area. This must be completed within one month. The bedrooms viewed on the day were well decorated. Personal items were seen in bedrooms belonging to service users. Many of the bedrooms have en suite facility of washbasin and WC. Those who were able said they were comfortable. During the inspection it was noted that cleanliness was to a good standard. In one bedroom there was a problem with odour control and this was discussed with the manager. During discussions with staff and from observations it was apparent that they had a good understanding of infection control policies and procedures. Paper towels and liquid soap were available in the laundry, kitchen, bathrooms and WC’s. Notices were displayed about towels and bars of soap being returned to bedrooms rather than leaving them in communal areas. The laundry provides one washer and a dryer. The washer conforms to infection control standards and has a high temperature cycle. The room was well organised and had named baskets for resident’s individual laundry. The manager confirmed that the housekeeper has two days supernumerary so that laundry and in particular ironing is monitored. Alexander Residential Home DS0000001409.V301649.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, 30. The quality of the outcome in this area is good. This judgement was made using available evidence including a site visit when documentation was inspected and discussions held with the staff on duty. The manager has ensured the protection of residents by obtaining CRB checks of staff working at the home. This would further be enhanced if references from previous care employment were always obtained. Relevant training that matches the needs of the residents is ongoing. EVIDENCE: The home was well staffed on the day of this unannounced inspection. The person in charge early in the day was the assistant manager who was aware of her responsibilities. A copy of the rota for the week of the inspection was seen and staffing levels were appropriate. The manager has increased staffing levels as required in order to meet resident’s needs. National Vocational Qualification (NVQ) training is on going. The requirement is to have 50 of care staff with level 2 or above NVQ qualifications. Currently the home has thirteen staff with NVQ level 2 training or above. This means the home has 80 of care staff with this qualification; others are booked to start the course. Some of the staff have NVQ level 3. Staff confirmed NVQ training during discussions and this was also evidenced in certificates of attainment and the pre inspection questionnaire (PIQ). Recruitment files for the latest three members of staff were checked. Application forms had been completed and two references sent for in all cases Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 18 tracked. All had received references but in one case there had been previous employment in a care setting but no request made for a reference from there. In order to fully protect the residents, a reference should always be requested from a former care employer. In addition, the applicant’s last 10 years of work experience (where applicable) should be ascertained. The manager confirmed that no work permits were required. Criminal Records Bureau (CRB) checks were available. The manager said that the Protection of Vulnerable Adults (POVA) first checks had been made but these records were at the Bury home. This information has to be available for inspection. Staff terms and conditions were available and there was evidence that staff had received an induction into working in the home. There was evidence of identity checks, qualifications and courses attended. This is as required. It was evident from the records and in discussions with staff that new staff receive an induction into working in the home. Induction includes health and safety such as fire procedures. In addition it refers to resident’s privacy and independence. Staff confirmed that the induction gave them a good basic understanding of the home’s practices, policies and procedures. However, in some cases this did not comply with the standard to complete within six weeks of employment. Staff training records showed that training is ongoing. Staff confirmed this as controlling food safety, moving and handling, introduction to dementia, fire drills and health and nutrition. Discussions about abuse and the protection of vulnerable adults had been attended. It was evident that training is encouraged in order to fully meet the needs of residents and protect them. Alexander Residential Home DS0000001409.V301649.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, 33, 35, 38. The quality in this outcome group is adequate. This judgement has been made taking account of available evidence including a site visit to the home, records and policies and procedures and discussions with the acting manager. The acting manager has appropriate management experience and skills. Quality assurance has begun but would be further enhanced with regular monthly reports from the providers. It is also the responsibility of the providers to ensure that all required records are on the premises to be inspected at any time. Health and safety is well managed but some issues are not dealt with speedily thereby putting people in the home at risk. EVIDENCE: The acting manager was formerly the registered manager and had been in post for many years. She terminated her contract in September 2005 but returned in January 2006. She was a registered nurse and has NVQ level 4 in care. She also has a City and Guild qualification in management. Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 20 Staff and residents spoke well about her management qualities. Staff meetings are held regularly and minutes were seen. Key workers talk to relatives about care plans and this is documented. Quality assurance (QA) monitoring has recently taken place that included the views of relatives and residents. Only one regulation 26 report about the conduct of the home to be completed by the providers has been made available to the CSCI. These should be done every month. The manager said that no valuables or monies are kept for safekeeping. The home does not deal with any personal allowances. The records of fees paid are kept at the Bury home. This record must be available for inspection. The manager has undertaken appraisal/supervision training and regular supervision of care staff is ongoing. These records were available for inspection. The records for fire safety were checked. The fire alarm test is carried out weekly and emergency lighting monthly. Staff fire drills are held. These were recorded with the names of those staff that attended. Staff confirmed this during discussions. Health and safety within the home was well maintained with some omissions. The bathroom flooring is unfinished in the ‘cottage’ area and presents a trip hazard. One bedroom window has no restrictors. Staff were observing the requirement to keep the fire doors shut near to the office but this causes difficulties when carrying objects for both staff and residents. With the agreement of the fire officer magnetic release devices would make access easier. Kitchen staff were not recording the temperatures of cold storage or hot foods. This record was introduced at the time of the inspection. Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 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 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 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. 2. Standard OP7 *RQN Regulation 15 17 Requirement All needs must be identified in a care plan. The registered person shall ensure that records are at all times available for inspection. This refers to contracts of residency and fees paid by or on behalf of residents. The registered person must comply with time scales. Previous time scales for completion of ‘cottage’ bathroom have not been met since 2004. The registered person must ensure that residents can access a safe outdoor area taking account of those with dementia. Consider replacing pattern with plain carpets to make it easier for those with dementia. The registered person must complete the work started in the cottage bathroom and put back in use. Ensure that references are obtained from previous employers in a care setting, where possible. Identify any gaps in work experience by DS0000001409.V301649.R01.S.doc Timescale for action 31/08/06 31/08/06 3 *RQN 19 31/10/06 4 OP20 23 31/10/06 5 OP21 23 31/08/06 6 OP29 19 31/08/06 Alexander Residential Home Version 5.2 Page 23 7 OP30 12, 13, 18 8 OP33 26 9 OP35 17 10 OP38 12, 13, 23 obtaining past 10 year work experience. All new staff must receive an induction within 6 weeks of employment and then foundation training within 6 months. The registered person must ensure that monthly reports following visits on the progress of the home are submitted to the manager and made available to the CSCI. The registered persons must ensure that records are available for inspection of fees paid by or on behalf of service users. The registered person must ensure that all windows at first floor level have restrictors. Keep up to date records of the temperature testing of cold storage and hot food. 31/08/06 31/08/06 31/08/06 31/08/06 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 Refer to Standard OP38 Good Practice Recommendations Involve the local fire authority in discussions about fitting magnetic release devices to the two fire doors near the office. In addition discuss how to fence off the side garden and make secure for residents whilst ensuring easy egress in case of fire. Alexander Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Residential Home DS0000001409.V301649.R01.S.doc Version 5.2 Page 25 - 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!