Inspection on 18/05/07 for Alexandra Care Home

This inspection was carried out on 18th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexandra Care Home 14/01/09

Alexandra Care Home 08/11/07

Alexandra Care Home 05/06/06

Alexandra Care Home 08/03/06

Alexandra Care Home 04/01/06

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Alexandra Care Home Doncaster Road Thrybergh Rotherham South Yorkshire S65 4AD Lead Inspector Ramchand Samachetty Key Unannounced Inspection 09:20 18th & 21st May 2007 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 Alexandra Care Home DS0000065779.V339105.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. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Care Home Address Doncaster Road Thrybergh Rotherham South Yorkshire S65 4AD 01709 850844 01709 854823 alexandra.rotherham@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited 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) ** Post Vacant *** Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (1) of places Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Category OP includes persons from 55 years of age One PD is to be used for respite purposes only Date of last inspection 5th June 2006 Brief Description of the Service: Alexandra Care Home provides Nursing and Residential care and accommodation for up to 47 people in the category of older adults from 55 years upward. The home is situated in Thrybergh, which is close to Rotherham town centre. It is within reach of a range of community facilities and is accessible by public transport. Accommodation is provided on three floors; the lower ground floor, ground and first floors. Access between the floors is by passenger lift and stairs. There are 41 single bedrooms one of which has en-suite facility, and three double bedrooms. Some bedrooms on the lower floor have access to the garden. There is a car parking area to the front of the home. The garden is fenced off and is provided with some garden furniture. Fees charged by the home are between £ 343.00 to £ 563.00 per week. Additional charges are made for hairdressing, private chiropody and other personal items of toiletries, newspapers and magazines. The registered person makes information about the service available to residents and their families via the home’s Statement of Purpose and the Service User Guide. A copy of the inspection report is made available at the home. Further information can be obtained from the home. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 18 and 21 May 2007, starting at 09.20 hours on the first day and finished at 16.00 hours. On the second day the inspection started at 09.45 hours and finished at 14.00 hours. The inspection was carried out by two inspectors. There were 24 people in residence at the time of this inspection, 14 of whom required nursing care. The person in charge of the home was Ms Liz Wass. She was joined later on by the Operations manager Ms D. Coy. All the key national minimum standards for ‘Care Homes for Older People’ were assessed and compliance with the requirements made at the last inspection was discussed. The inspection included a tour of the premises, examination of care documents and other records, which included medication, complaints, care records and staff files, conversations with six people living at the home, eight relatives and seven members of staff besides the manager. The care of three people who use the service was tracked and some aspects of care were observed. Feedback on the findings of the inspection was given to the manager, the operations manager and to another senior manager who was present at the home on the last day of the inspection. What the service does well: What has improved since the last inspection? All the bedrooms on the lower ground floor have been refurbished and decorated. The bedrooms in this part of the home have been designated for use by people who need personal care only. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 6 New care planning documentation has been developed and has been put in use at the home. This has led to an improvement in the care planning process. What they could do better: Assessment of needs of individuals using the service was adequately carried out prior to admission, but staff must keep such assessment under review in order to ensure that changing needs could still be met. Although improvement has been made to the care planning process and to care documentation, there is a continuing need to make sure that all identified care needs are appropriately addressed. Care plans must be developed in a more holistic way and they must be reviewed regularly. In planning and providing care, the use of restraint must be appropriately assessed, recorded and reviewed. The quantity of medicines received at the home must be appropriately recorded and proper stock control must be exercised for each person ‘s medicines. The provision of social and recreational activities must be in line with the preferences and capabilities of people who use the service. People living at the home must be offered opportunities and pro-actively encouraged to exercise their choice of food. The management of complaints, concerns and allegations must be improved so that relevant investigations, outcomes and actions taken are appropriately recorded. Details regarding the management of personal allowances of people living at the home must improved to show the records pertaining to individual accounts. Although there is a refurbishment programme for the home, the registered provider needs to carry out the necessary repairs to the building and its fixtures and fittings. The standard of cleanliness and hygiene must be improved. Improvements are required in the compliance of fire safety regulations These actions will help make the home a safer and more pleasant place to live and work in. The number of care staff deployed on duty, especially during the night must be increased to make sure that the needs of people living at the home can be effectively met. The care staffing level needs to take into account the needs of people living at the home and the lay out of the building. There needs to be sufficient domestic staff on duty to make sure that a good standard of hygiene can be maintained at all times. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 7 There is a need to make sure that the recruitment and selection of staff is appropriately carried out in order to safeguard the safety and welfare of people who use the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service had sufficient information to enable them and their representatives to make a choice of care home. Assessments were undertaken before people were admitted to the home to make sure that their needs could be catered for. EVIDENCE: The home has produced a statement of purpose and a service user guide. Both documents reflected the changes in ownership and the management of the home and contained all the relevant information. Copies of the statement of purpose and service user guide were placed in all bedrooms of people living at the home and for their relatives to read. Staff confirmed that copies were sent out to people who were interested in a placement at the home. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 10 Care files checked showed that people using the service had a full assessment prior to admission. These were undertaken by their placing social worker, under the care management approach, or by senior staff of the home, if they funded their own care. The home does not provide intermediate care. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience poor outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People living at the home were generally satisfied with the care they were receiving. Although the care planning system was being improved, there were inconsistencies in the way care plans were developed and implemented. In some cases, this had led to inadequate care being given. The management of medicines was not in line with the home’s policy and procedures and this could adversely affect the health and welfare of people using the service. EVIDENCE: People living at the home were generally satisfied with the way care is provided to them. They commented that their personal care was carried out in the privacy of their bedrooms and in bathrooms. People using the service were provided with individual care plans. Four care plans were checked. The care of three people living at the home was case tracked (examined in some detail). Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 12 Care plans were based on assessed needs and risks. It was noted that care plan documentation had been improved and that staff were receiving training on the development and implementation of care plans. There were, however, a number of inconsistencies in the care planning process. Some care plans did not address relevant health, personal and social care needs in a holistic way. There was little evidence that people using the service and their representatives were involved in developing their individual plan of care. The care plan of one person showed that she had been assessed as suffering from confusion that led to behavioural difficulties, but there was no plan of action to address this specific issue. Individual assessments of people using the service were not always reviewed to ensure that changing needs, in particular health care needs were appropriately addressed. A person living at the home who was assessed as being self-caring had gradually become more dependent and was unable to maintain her hygiene needs. The care plan failed to reflect this change, although the issue was mentioned at a care review. One person pointed out that his specific recreational and social care needs were not being met and he had therefore raised the matter in his care review, but no records were seen to that effect. The care plan for one person who was suffering from a pressure sore, was appropriately laid out and included actions to take in managing it, whereas in a comparable situation, there was a lack of information about how a wound should be managed. In another instance, it was not clear in the care plan, whether the advice from the “tissue viability nurse” with regards to pain management, had been followed. Records about care provided were very often too generalised and lacked details, in order to be of effective use in subsequent care evaluation. This was particularly evident in the care records made during night- time. In one instance, night care records showed that one person was placed in a ‘recliner’ chair once she was up, to prevent her from to moving as she had a tendency to fall. Risks faced by people using the service in their daily activities of living were assessed and managed. Care plans which were checked, showed that they were not consistently reviewed on a monthly basis. Health care needs were not appropriately addressed in care plans, for example, the specific care the needs of a person who had visited the accident and emergency unit with chest pain and low blood pressure were not included in his care plan. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 13 The manager stated that the home had a policy and procedures for the management of medicines. The medicines of people with nursing needs were administered by nursing staff and for people with personal care needs only, by care workers who had been trained to do so. Different trolleys were used for the two groups. The medicines trolley for people with personal care needs was inadequately stored. Medicines records for this client group were appropriately maintained. A sample of medicines administration records (MAR) sheets for nursing clients was checked. The amount of medicines received at the home was not recorded. This hindered the monitoring of medicines. During the inspection, it was noted that a prescribed item of medicine for one person (October 2006) who was no longer at the home, was administered to somebody else who needed the same medicine, but had apparently ran out of stock. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service felt that routines at the home were, in general, flexible but that there was a lack of opportunities for recreational and social activities to enhance their quality of life. Meals served at the home were of a good quality but choices were sometimes limited because menus were not consistently followed. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 15 EVIDENCE: People living at the home were observed spending most of their time sitting in the lounges and in their bedrooms, in between meals and care interventions. A number of people stated that there was very little to do except watching television. One person said that he felt restricted in “where he could go and what he could do”. Another person stated that she was keen to “ play bingo and dominoes whenever I have a chance”. A small number of people stated that they “felt bored”. Some people said that the activities co-ordinator was good when she was around but felt she did not work for enough hours to be able to effectively improve their social life. They said that they liked some of the indoor activities she had put on for them. Relatives confirmed that staff were always busy and did not seem to have time to sit and talk to with their loved ones. People living at the home said that they could exercise choice in some areas of their daily activities, for example when they go to bed and when they get up and what to wear. The manager commented that information about social activities was displayed on a notice board. Care plans indicated that social history of individuals was not always used to assist in the planning of activities. Relatives said that they were welcomed at the home. They could see their loved ones in the privacy of their own rooms. People using the service and their relatives said that the meals served at the home were usually good and tasty. Some people spoken to stated that they had three meals a day, including breakfast. They said that supper was not always offered. The main meal was served at lunchtime and this was observed during the inspection. Staff explained that people using the service, had chosen their meals the day before. The food was placed in a hot trolley and transported to the dining room, where it was then served. The menu for the day comprised of fish or faggots with chips and mushy peas. Plenty of drinks were offered. Deserts were not served as stated on the menu and one person was unhappy not to have been served with rice pudding. Other people also commented that they hardly “get what’s on the menu”. Staff were observed providing some assistance to a small number of people, with cutting their food and with feeding them. Some people said that they had not been offered a choice of where they wanted to eat their meals. One person said that she would have preferred to have her meals in the lounge but had not been allowed to do so. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management of complaints was not in line with the home’s policy and procedures and was unsatisfactory. e Procedures to deal with and monitor issues relating potentially to the safety and welfare of people living at the home were not always adhered to. This could put people at risk. EVIDENCE: A complaints procedure was in place and was made available to all those using the service and their representatives through the home’s service user guide. A few people who live at the home and their relatives confirmed that they were aware of the procedure and would use it if necessary. The home had received nine complaints since the last inspection (June 2006). The complaints records showed that a few of them had not been fully investigated and appeared not to have been resolved. Complaints investigations and their outcomes were not always appropriately recorded. In one instance a complaint received in July 2006 had not been followed up and was still waiting to be dealt with. The manager stated that these shortfalls were due to the changes that the home was undergoing since last year. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 17 There was a policy and procedures for safeguarding vulnerable adults. The policy was in line with the ‘No Secrets’ document and referred to the local adult safeguarding team. There had been three investigations into adult protection issues at the home since the last inspection. Staff spoken to, confirmed that they had recently received a half day training on adult protection issues. However, an allegation of inappropriate conduct of staff and of the behaviour of a person living at the home was made during the inspection. The informants confirmed that the issues concerning the behaviour of the individual had been raised with the home management and that the matter had not been addressed. There were no records of this allegation being received by the home manager. A senior manager of the service agreed to take the appropriate action to deal with the allegations regarding the staff member and that of the identified individual living at the home. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home were satisfied with the standard of accommodation they were provided with. Although a refurbishment plan was in place, additional repairs and compliance with fire safety regulations had not been identified for remedial action. The standard of hygiene was not consistently good due to a shortage of domestic staff. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 19 EVIDENCE: A tour of the premises was carried out in the company of the manager. Only the main entrance was fully accessible to wheelchair users and the bell on the door was noted to be beyond their reach. One wheelchair user who lives at the home stated that he could use one other door to get out of the building but it was not quite levelled and so had to manoeuvre carefully. Externally, a number of wooden windows and doors were showing signs of increased deterioration. Internally, some parts of the accommodation have been refurbished. The lower ground floor has been allocated to people who require personal care only. The bedrooms in this section have been decorated and new carpets have been provided. Toilets and other hygiene facilities were located nearby. There was also a lounge. The ground and upper floors were used for people who required nursing care. Apart from individual bedrooms, there were three lounge areas and a large dining room. However, people using the service said that they spent most of the daytime on the ground floor. Equipment was available to help people living at the home with their activities of daily living. These included hoists, walking frames and a number of pressure relieving mattresses. There was an area of dampness in one bathroom and that had caused the paint and underlying plaster to peel off. One bath panel was broken and had some rough edges. Two extractor fans located in toilets were not in working order. One of the bedrooms was noted to have persistent malodour although it had new carpet. The laundry room was divided into two areas. One area contained the washing machines and dryer and the other part had been partitioned to form a separate area for ironing and for storage. Access was obtained through a fire door, there was no ventilation in this area and the fire door was tied open to allow for air circulation. As this constituted a fire hazard, the inspector advised that the door be untied. This was immediately done. People living at the home stated that they liked their bedroom. One person said that he liked using one of the front lounges to meet with his relatives because it was “quiet and comfortable”. Another person said her room was spacious and was therefore able to bring a few memorabilia to personalise it. Several parts of the home were found to be dirty. A number of communal and private areas, including the surfaces of furniture were found to be quite dusty. In discussion, it was noted that there was shortage of domestic staff due to unfilled vacancy and to sickness. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 20 The grounds surrounding the home appeared adequately maintained for the time of the year and were tidy. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Although people living at the home said that they were, in general, receiving a good standard of care, the staffing level was not consistently sufficient to meet needs, in particular at night. There were shortfalls in the staff recruitment and selection procedures, which could lead to inappropriate staff being recruited. Staff were satisfied with the training they were receiving and this helped them in improving care provision. However, staff supervision arrangements were inadequate and this could affect staff performance and development. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 22 EVIDENCE: There were four care staff, two first level nurses and the manager on duty on the morning of this inspection. One of the nurses was a recent recruit to the staff team and was on induction. There were 24 people living at the home and 14 of them required nursing care and 10 needed personal care only. A first level general nurse was on duty at all times. However, only two carers were deployed during night hours. In discussion, people who live at the home and their relatives were satisfied that there were currently enough staff during day time to provide the care and support needed. However, they were less confident about the level of staff deployed during the night. Staff commented that there were a number of people who needed two members of staff to move and handle them. Insufficient staff were deployed and this made it difficult to effectively supervise the three floors. In discussion, it was noted that there also were difficulties in deploying domestic staff. This was due to staff absence. The manager stated that she was trying to recruit a part time domestic to help with the cleaning duties. The home had use of a corporate recruitment and selection procedure. This included an equal opportunities policy. Job application forms were noted to have an equal opportunities monitoring questionnaire attached to them, but it was not clear how the information derived from them was used. There was a small number of staff that reflected the Black and Minority Ethnic communities and they were primarily from abroad. The records of two members of staff recently recruited were checked. The actual CRB certificates were not available at this inspection. There was information that disclosures from the Criminal Records Bureau (CRBs) had been obtained. However, the information was not sufficient to assess whether satisfactory CRB’s had been received prior to staff working at the home. In one instance references for a new staff member were sought and obtained from her friend and one of her past employers. Another member of staff had given only one written reference from a friend. Fifteen of the twenty care staff working at the home had achieved their National Vocational Qualifications (NVQ) level 2 in care. Staff spoken to, confirmed that they had received training on a range of topics, including moving and handling, fire safety, food hygiene, infection control, management of pressure sores and adult protection. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Although some quality monitoring and quality assurance measures had been put in place, the management of the home was weak and reactive. Record keeping was poor and could affect the interest of people using the service. Health and safety issues were not satisfactorily addressed and this could put people who live and work at the home at risk. EVIDENCE: The home is part of a national provider group and is overseen by an Operations Manager to whom the home manager is accountable. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 24 The manager was appointed in January 2007 and has not yet registered with CSCI. She is a first level general nurse and has a diploma in Nursing Studies. She has also achieved a National Vocational Qualification, level 4 in management. In discussion, it was noted that the provider had started to improve the management of the home by providing additional support to the home’ s manager and by introducing a few quality- monitoring procedures. These included audits of accident records, catering, medicines and care plans. An accident analysis audit was checked. It gave the number of accidents, including falls each month. There was no information about time or place of these accidents. It was not clear from the audit what actions were taken to reduce accidents and incidents at the home. The manager stated that a satisfaction questionnaire was distributed to approximately 30 people who use the service and their relatives, in December 2006. Twenty completed questionnaires were returned and the feedback was positive. Two areas where improvement was suggested were catering and laundry services. The manager said that an action plan had been developed and implemented. The manager stated that other quality measures used, included “Residents’ Meetings and Staff Meetings”. People living at the home said that the senior managers of the home had held a meeting in the home and they did not know when the next one would be. Staff confirmed that the manager was holding short staff meetings every week as a way of informing all staff about care and management issues. Some members of staff stated that they were receiving supervision but not on a regular basis. Examination of staff files indicated that not all staff were provided with supervision. The manager stated that arrangements were in place to assist people living at the home to manage their personal allowances, if they or their relatives were unable to do so. The home had a nil interest bank account in which individuals could put their money. Staff were helping 17 people using the service to manage their personal allowances. However, there were no records available to check the incoming and outgoing payments form individual accounts. It was therefore not possible to check the balance on individual accounts. The representative of one person who lives at the home, stated that one of his difficulties, was about the management of his money because he had no ‘capacity’ to manage his own affairs. He was going to meet with the manager to resolve this difficulty. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 25 Record keeping in medicines management and in staff files is also poor. It was noted that a few management tasks were delegated to other staff and the manager did not appear to be getting any feedback about these tasks. This was evident in the handling and management of personal allowances of people living at the home and of health and safety issues. The manager stated that there was a health and safety policy to guide staff on issues of safe working practices. Staff were also provided with training on health and safety issues. During the inspection, it was noted that fire doors were kept open and this is contrary to fire safety requirements. The manager stated all equipment and major utilities used at the home were regularly maintained. Certificates of maintenance for a number of hoists were seen. A number of people living at the home and some relatives stated that the passenger lift did not work well and that it was “always breaking down and that it could not be trusted”. Staff also confirmed that there were problems with the lift and it frequently broke down. One relative said that when the lift broke down sometime in March 2007, people who lived on the lower ground floor had to stay down. During the inspection, it was noted that the passenger lift was dimly lit and was rather slow. There was no record of any problems with the lift. The handyman said that he did not usually write every request for repairs in his book and that he had on occasions requested the maintenance firm to check the lift. There was no current certificate of examination and maintenance of the passenger lift (Lifting Operations and lifting Equipment Regulations- Loler). The manager stated that a ‘ Loler’ examination had taken place in January 2007, but the certificate was not kept at the home. A copy from the company’s office was faxed to the home during the inspection. It showed that a few defects had been identified and action to rectify them had been recommended. There was no evidence that appropriate action had been taken as suggested in the ‘Loler’ certificate of 4 January 2007 or in light of ongoing concerns from people who live and work at the home. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 1 2 X 1 Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 OP8 Regulation 15 Requirement Care plans must address all the assessed health, personal and social care needs of people who use the service. Records about care provided must be improved. Care plans must be reviewed within the required frequency. (Not fully met by previous timescale of 01/09/06) Individual assessment of people using the service must be appropriately reviewed to make sure changing needs are identified and addressed. The use of restraint must be appropriately assessed, recorded and reviewed. Medicines prescribed for one person must not be administered to another person. Medicines received at the home must be appropriately recorded and stock control improved to allow for timely re-ordering of medicines. Recreational and social activities must be developed in line with the preferences and capabilities of people who use the service. DS0000065779.V339105.R01.S.doc Timescale for action 16/07/07 2. OP7 14 16/07/07 3. 4 5. OP7 15 13 13 16/07/07 30/06/07 16/07/07 OP9 OP9 6. OP12 16 30/07/07 Alexandra Care Home Version 5.2 Page 28 7. OP14 12 8. 9 OP15 OP16 12 22 Staff must make sure that people using the service are able or are appropriately assisted to exercise choice and control with regards to their activities of daily living. Menu choices must be provided to people living at the home, at all times. Complaints must be appropriately investigated and records must be kept of their investigation, outcomes and any action taken as a result. Any allegation or concern about potential abuse must be promptly addressed and adult protection procedures implemented. The deteriorating wooden windows and doors must be repaired or replaced. The wall damage identified in one bathroom must be repaired. The extractor fans, identified, which were not in working order must be repaired or replaced. The section of the laundry which is used for ironing must be appropriately ventilated All parts of the home must be kept clean and hygienic at all times. The level of care staff deployed at night, taking regard of the levels of occupancy and needs as at the inspection date and also the lay out of the building, must be increased by at least one, to bring the total number of care staff to not less than three. This staffing level must be kept under review to make sure that the needs of people living at the home can be met at all times. Sufficient domestic staff must be employed to ensure that the DS0000065779.V339105.R01.S.doc 16/07/07 16/07/07 16/07/07 10 OP18 13 30/06/07 OP19 11 12 OP19 23 23 13/08/07 16/07/07 13 14 OP26 16 18 16/07/07 16/07/07 OP27 15 OP27 18 16/07/07 Page 29 Alexandra Care Home Version 5.2 16 OP29 19 17 OP29 19 18 OP35 12 19 OP36 18 20 21 OP38 13 13 OP38 home can be kept clean and hygienic at all times. Two written references must be sought and obtained from appropriate persons before staff are employed to work at the home. (Previous timescale 01/09/06 not met) Confirmation that satisfactory CRBs have been obtained for each member of staff prior to them working in the home must be available at inspection. Records for all incoming and outgoing payments on individual accounts of people who are assisted with the management of their personal allowances, must be appropriately kept and made available at inspection. All staff must be provided with appropriate supervision with the required frequency. (Previous timescale of 01/09/06 not met.) Fire doors must be kept closed at all times unless they are fitted with automatic door releases. The condition of the passenger lift must be improved to make sure it is safe and comfortable for use. 16/07/07 16/07/07 16/07/07 16/07/07 16/07/07 16/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations The accident analysis audit should include details of the time and location of accidents that happen at the home. Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexandra Care Home DS0000065779.V339105.R01.S.doc Version 5.2 Page 31 - 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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