Inspection on 04/01/06 for Alexandra Care Home

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 18/05/07

Alexandra Care Home 05/06/06

Alexandra Care Home 08/03/06

Similar services:

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Snydale Care Home

Larchfield Manor

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The Grove Waltham

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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 Janet McBride Unannounced Inspection 4th January 2006 10:15 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.V274868.R01.S.doc Version 5.1 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.V274868.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alexandra Care Home Address Doncaster Road Thrybergh Rotherham South Yorkshire S65 4AD 0207 9293444 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) Ashbourne (Eton) Limited Mr Timothy Michael Yates 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.V274868.R01.S.doc Version 5.1 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 Brief Description of the Service: Alexandra Care Home provides Nursing and Residential care and accommodation; it is registered for 47 beds. The home is situated in Thrybergh, which is close to Rotherham town centre. Accommodation is provided on three floors, which are accessible, by a passenger lift, there are 41 single bedrooms one of which have ensuite facility, and three double bedrooms but at the present is being used as single. Some bedrooms on the lower floor have access to the garden via a patio door in their bedroom. The garden is fenced off, with garden furniture for service users to sit outside or have a walk if they choose. There is ample car parking area to the front of the home. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last Inspection Ashbourne (Eaton) Ltd applied to the Commission for Social Care Inspection to register as proprietor of Alexandra Nursing Home which is an existing care home providing a service for 47 service users. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Alexandra Nursing Home, on the 4th of January 2006, commencing at 10:15 and finished at 17:30 During the Inspection we looked at a number of standards, a chosen number of documents, sampling of records, tour of the premises and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with staff, residents, and comments from visitors on the day. Any issues or concerns that were raised were discussed with the Manager during and at the end of the Inspection. What the service does well: What has improved since the last inspection? General appearance of the home has improved, and since the last inspection the home has continued with their redecoration programme both internally and externally, and changes to the lounge and dining areas as made a big improved to the communal areas of the home. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 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 Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 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): 356 All residents are fully assessed before being admitted to the home, to ensure the home can meet their needs and that they are appropriately placed and their needs can be met. EVIDENCE: The home offers residential and nursing care but not intermediate care. Evidence seen in care plans that residents are assessed prior to admission, various assessments were documented, depending on the need of the individual. These assessment provided details of current abilities, needs and social background of residents, to enable staff to complete care plans. Prospective service users and their relatives have the opportunity to visit and have a look around the facilities, and trial visits can be arranged. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 10 Medication at this home is well managed promoting good health, and care needs fully met, also ensuring that Resident’s are treated with respect and their privacy upheld. EVIDENCE: Care plans were not case tracked on this inspection, therefore only some care plans were checked for information and discussion with the manager. Medication policies and procedures were discussed with the clinical manager and records checked including stocks of medicines and controlled drugs all of which provided evidence that Medicines in the custody are handled according to the requirements of the Medicines Act; for example random MAR sheets were satisfactory and well maintained and Controlled drugs were checked and evidence was seen that they are administered correctly with the required records kept. Residents seen were appropriately dressed with any aids they require, for example glasses and hearing aids. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 10 Those residents spoken to confirm they were happy with care they received, and the staff at the home, stated they receive their personal mail unopened and have access to a telephone. There were many examples of good practise observed on the day, good interactions between staff and residents, and most residents were referred to by their first name and this was with the approval of residents and would be recorded in their care plan. Staff spoken to confirm they always give personal care in private and treat residents with respect and dignity. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Social activities are organised to provide stimulation and interest for residents and dietary needs of residents are well catered for with a balanced and varied selection of food available. EVIDENCE: Routines within the home appear flexible and quite a few of the resident’s were able to give their views on life within the home. The home have an activities organiser who works three days a week, but some residents stated that they would like more activities to be available, activity hours were discussed with the manager and this may need re-assessing to ensure that they are meeting residents needs that satisfies their recreational interests. Visitors were in and out of the home most of the day, when they were spoken to confirm they could visit at any time, and could see their relative in either the lounge areas or the resident’s own bedroom. Staff was indirectly observed throughout the Inspection, good interactions between staff and residents and the visiting relatives, staff encouraged residents to make choices whenever possible. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 12 It was evident that during a tour of bedrooms most had been made very homely with resident’s personal possessions in their rooms. Ashbourne have made some changes regarding catering at the home, Eurest provide catering and staff at the home. Menus seen appear to offer a balanced and varied diet, when the catering/cook was interviewed he confirmed that food and drinks always available for residents, all residents have nutritional assessment completed and dietician is used when needed. Observation at mealtime was unhurried and residents that need assistance, staff ensured this was given individually, all residents spoken to state that food at the home is good and always have a choice. Some issues were raised regarding equipment in the kitchen for example only one fryer working and the grill stopped working today also on the kitchen range it does not ignite properly. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and their care. Staff had knowledge and understanding of adult protection issues, which promotes protection of residents from abuse. EVIDENCE: Ashbourne complaints policy and procedure is clear and accessible to all residents and visitors, this procedure was discussed with the manager, and complaints records checked. Two complaints since the last Inspection and records show that these had been dealt with promptly and fully investigated with reports available. The home has policies and procedures for adult protection; manager aware of local adult protection team and staff spoken to confirm they are aware of these polices and procedures, including whistle blowing. All staff has CRB checks completed before commencing employment. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 14 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 26 General appearance of the home has improved with some decoration, but a number of issues were raised on this inspection with regard to equipment that staff need for environmental standards, and residents welfare. EVIDENCE: Since the last inspection the home has continued with their redecoration programme both internally and externally, and changes to the lounge and dining areas as made a big improved to the communal areas of the home. Tour of the premises found toilet and washing facilities sufficient with accessible toilet near communal areas. Since the last Inspection some of the toilets that were not used have been made into storage space that the home find very useful. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 15 Tour of the bedrooms found them to be clean and comfortable, and a number of bedrooms had been refurbished with furniture, new bedding and curtains, some still waiting for carpets, and residents seem delighted with the change. One issue raised was adjustable beds this was discussed with the manager, has the majority of the homes residents require nursing care. From taking to staff that deliver the care, reading of care plans and observation during the Inspection, it seems evident that a number of these residents need adjustable beds as stated in standard 24(3) therefore the home need to evidence of assessment stating why this would not be suitable option. Laundry facilities are sited on the lower ground floor of the home and have the appropriate facilities, with the exception of colour coded skips for laundry. Separate storage for clean laundry was seen and found that some of the bedding was very worn, however during a discussion with the housekeeper she informed us that this had been ordered. The home has ancillary staff including domestic staff in appropriate numbers but the home only as one industrial cleaner, and one domestic trolly, therefore the domestic staff can not clean all floors together, this does not seem adequate for a home this size, and requires addressing. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 16 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 30 Staff have the skills and knowledge to fulfil their roles within the home, but the registered provider must provide appropriate training especially for new staff to ensure that residents needs are met. EVIDENCE: Staffing numbers and skill mix was discussed with the manager, who confirmed that resident’s dependency levels are monitored and re-assessed on a regular basis to ensure care needs are met. Other staff members within the home are activities organiser and ancillary staff that is employed in sufficient numbers to ensure standards are met. Training was discussed with both the manager and the homes training coordinator, in the past training has been excellent and stored 4.Since Ashbourne have taken over they have changed the way they deliver staff training, and this raises issues. New staff has induction to the home but no evidence was found that staff receive foundation training that equips staff to meet the needs of residents. Some staff require moving and handling updates, however evidence was seen that this is arranged. Nurses have always been able to access yearly updates on clinical practices, these are external courses and some have had to be cancelled due to shortage of staff, but the Registered provider must ensure that nurses have access to clinical updates when required. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 17 Care staff within the home can access NVQ training and this was discussed with the manager, although a number of care staff has completed their NVQ level 2, therefore the home are on the way to achieve 50 of staff being NVQ trained. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 18 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 home is managed properly and the manager offers leadership, guidance and direction to staff to ensure that residents receive consistent care; these practices promote and safeguard the health, safety and welfare of residents within the home. EVIDENCE: The manager is competent and experienced to run the home, being a qualified nurse and vast experience within the NHS and private sector. The manager tries to run the home in the best interests of residents, and has carried out a complete audit of the home that was available to examine. Accident reports analysed on a monthly basis, some care plans audited but not on a regular basis. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 19 Discussed with the manager residents finances who stated that he ensures that residents control their own money except where they state that they do not wish to or they lack capacity. Discussed health and safety with the registered manager, staff that were spoken to and records checked. The manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff within the home. The homes safe working practice was observed and tour of the building saw safety notices posted a number of records were examined; all of which indicated that fire drills and training had taken place on a regular basis, and this was confirmed by the members of staff spoken to. Records also show that servicing of appliances has been completed e.g. Lifts and hoists have been serviced, and certificates issued. Most of the nursing staff has completed a four-day first aid course, this ensures that an identified first aider on duty at all times. Records show that staff receives mandatory training but some staff require updates in moving and handling, but evidence was seen that this had been organised. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 21 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 OP15 Regulation 23(2)(c) Requirement Timescale for action 28/02/06 2 OP24 23(20(c) 3 OP26 23(2) (c) 4 OP30 18(1)(c) The Registered provider must ensure that equipment remains in good working order, with regards to the equipment in the kitchen. Adjustable beds must be 31/03/06 provided for nursing residents, or provide evidence that these are not suitable. 1) Laundry facilities must have colour coded skips for infection control. 2) Domestic facilities must 28/02/06 ensure that domestic staff has the equipment to complete tasks with regard to industrial cleaner and domestic trolley. Training; The Registered 31/03/06 provider must ensure that new staff must receive foundation training to NTO specification to equip them to meet service users needs. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 22 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 OP12 OP31 OP28 Good Practice Recommendations Residents should have the opportunity to satisfy their social and recreational interests, Re extra activity hours. The registered manager must achieve NVQ 4 in management. 50 of care staff must be trained to NVQ Level 2 or equivalent. Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Alexandra Care Home DS0000065779.V274868.R01.S.doc Version 5.1 Page 24 - 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. 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