Inspection on 05/06/06 for Alexandra Care Home

This inspection was carried out on 5th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexandra Care Home 14/01/09

Alexandra Care Home 08/11/07

Alexandra Care Home 18/05/07

Alexandra Care Home 08/03/06

Alexandra Care Home 04/01/06

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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 Ms Rosemary Reid Key Unannounced Inspection 5th June 2006 11:10 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.V298369.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.V298369.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 0207 9293444 NONE NONE 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.V298369.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 8th March 2006 Brief Description of the Service: Alexandra Care Home provides Nursing accommodation; it is registered for 47 beds. and Residential care and The home is situated in Thrybergh, which is close to Rotherham town centre. Accommodation is provided on three floors, for example lower ground floor, ground and first floor, which are accessible, by a passenger lift; there are 41 single bedrooms one of which has ensuite facility, and three double bedrooms which at this time are as single occupancy. Some bedrooms on the lower floor have access to the garden via a patio door in their bedroom. Alexandria Care Home stands in is own grounds but is on a main road with regular bus services with bus stops nearby the home. There is a car parking area to the front of the home. The garden is fenced off, with garden furniture for service users to sit outside or have a walk if they choose. Fees for Nursing Care Social Services are Medium band £427,High band £477 Private Nursing Care, Medium Bank £505 less £83 free nursing care, Private Nursing High band £505 less £133 free nursing care, Residential Care £329 – £375 as at 1st April 2005 and additional charges are made for hairdressing from £4:00, National Health Service Chiropody free if qualify to their criteria, two private chiropodists visit the home fees from £9:50 - £18 depending on treatments, Optical, Dental services, specialised toiletries and magazines etc. 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. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 5th and 6th June from 11:10am to 3:40pm and 8:00 to 4:45 respectively to assess National Minimum Standards for Older People. This was the first inspection of the home by this inspector. The inspection focused on the requirements from the previous inspection of March 2006, four residents’ files were case tracked along with all the key standards of the National Minimum Standards for Older People and four staff records were also assessed. The home has been taken over twice since April 2005. The company that presently owns Alexandra Care Home is Southern Cross. The home is in a transitional stage with both companies’ administration systems and care plan formats. The previous manager left in April 2006 and the appointed manger is Mrs Eileen James (who is a Project Manager with Southern Cross) who will be working at the home until a permanent manager is appointed. Her remit is to put into place systems and the upgrading of the home. At the point of the inspection Mrs James has been at the home for a period of four weeks. Four residents files (two files from nursing care and two files who have residential care) were cased tracked. Supporting documents were also seen for example home’s desk diaries, medication records, staff files and Health & Safety records. Four staff files were also assessed. The home has an activities organiser with a limited range of activities. All residents were observed and many were spoken with. Two visitors to the home were interviewed who both spoke about the home in positive terms about the care give by staff. The inspector spoke with six staff members, four nurses and the manager over the two visits. In a discussion with one resident concerns were raised and the manager was asked to meet with the resident to listen to the concerns and this was done immediately. A tour of the premises/environment/front and rear gardens showed that work is currently being undertaken. Sixteen survey satisfaction feedback questionnaires and pre-paid envelopes were left at the home for the residents or relatives to make their comments were left at the home. At the point of writing two replies from the questionnaires had been received. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 6 A further visit was arrangement to visit on the 21st July at 6pm to meet with residents and relatives to obtain their opinions and to ascertain progress of the service and will be written about in the next report. Feedback of the inspection was given to the Mrs James, the appointed manager What the service does well: What has improved since the last inspection? Consultation by management with residents and relatives, audits have been undertaken and a plan to bring the home up to standard. The outside of the home has been brighten by the use of plants in urns, hanging baskets, mangers planted with flowering plants There is a decoration programme for the home with the dining room and some bedrooms have been completed. A number of bedroom carpets have been fitted, curtains and bedding purchased. The home had only one vacuum cleaner and another vacuum cleaner had been purchased. There have been changes to ensure that the home is kept clean. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 7 A new cooker has been ordered and the kitchen has been thoroughly cleaned. A new cook is in post and has been given control of food budget. Residents said that food and meals had improved in recent times and there was more choice and variety. The service is working to have separate nursing and residential areas within the home to concentrate nurse time on nursing tasks and their individual care needs and for the people who require residential care have their individual needs catered for. Some residents have moved bedrooms and in discussions with them they said that they are pleased with the changes. This is also working in conjunction with the redecoration programme. What they could do better: The daily recording was not done each day therefore did not have up to date information and care plans had not been reviewed monthly. The new manager said that she would ensure that care plans are audited and that staff must write up to date information. Medication storage is poor as there is little ventilation with no facilities for staff to wash their hands. The fridge, which is used for the storage of medication, did not have a lock and this fridge was stored in the nurses’ office. The manager stated that she is looking at changing the offices to ensure improved facilities for nurses and the storage of medication. Oxygen cylinders were correctly stored in a cupboard with a notice on the door however there was an oxygen cylinder in the nurses’ office, which did not have a notice on the door as per Health & Safety regulations. There was not enough room for the cylinder to be stored in the medication cupboard. The nurses and administrators offices are also used as storage areas. Toilets and bathrooms used as storage area. As soon as this was highlighted the manager took action to have items located in appropriate places. One lock on the outside of a toilet door was inappropriate and when this was identified to the manager she took immediate action to have the lock removed. Staff supervision and annual appraisals had been undertaken on an ad hoc basis. The manager was asked to provide a plan for the year for staff supervision and annual appraisal, which she sent by email. The home was in a transitional stage with two takeovers and the previous manager leaving. The new manager was in post for a period of four weeks at the time of inspection. As a result of these issues staff moral was low. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 8 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.V298369.R01.S.doc Version 5.2 Page 9 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.V298369.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good, and this judgement has been made using the evidence available. Service users and prospective service users have up to date information regarding the registered provider. An assessment of need is undertaken and all service users have a contract/statement of terms and conditions of residency, which safeguards their legal rights. Intermediate care is not provided in Alexandra Care Home however, the service offers short stays and respite care. EVIDENCE: The service has developed a Statement of Purpose and the Service User Guide; both had gone to head office for updating due to the recent take-over and the change of manager. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 11 In discussions with service users, family and staff confirm that previously the Service User Guide had been given to prospective service users and/or relatives. The four service users’ files that were case tracked had copies of contract/statement of terms and conditions of their residency and delivery of care. Records show that pre-admission assessment is undertaken and this was recorded within the individual service user’s care file to ensure that the home can meet their needs. Records show and in discussions with service users and families confirmed that the home welcome visits before admission to assess the quality, facilities and suitability of the home. The home does not offer intermediate care. There was evidence that respite care provision is used. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 12 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 poor, and this judgement has been made using the evidence available. Arrangements for dealing with resident’s health issues are adequately met by staff at the home, with support from health professionals. From the sample of four files the company’s care planning systems are sufficiently detailed to enable staff to deliver the care to residents who have specific identified needs and promoting good health. However, the sample of four care files did not contain up to date information and are not reviewed monthly. A number of senior staff are not working to the organisations policies and procedures for administration of medication. EVIDENCE: Four care plans were case tracked and examined. Care plans are currently being changed to the new Southern Cross format. Care plans were not reviewed monthly. There is evidence within individual residents’ care plans that consideration is given by staff to the areas of race, ethnicity, sexuality, gender, disability and belief. Files did not have up to date information recorded in the daily recording records. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 13 The temperature of the fridge for medications is taken and recorded however there is no lock on this fridge and is placed in the nurses’ office. Nurses administer medications. Records for the administration of medications were assessed which were found to be correct. The company have policies and procedures for the administration of medications. The nurses’ office was being used as a storage area for boxes of nutritional supplements and supplies of fluids, which was a hazard. Once highlighted the supplies were moved to provide easier access to the office facilities. The fridge in which medication is stored located in the office did not have a lock. There were issues with the temperature of the storage of medication in the locked cupboard with had little ventilation. Oxygen was stored in the office without a health and safety poster. When this was highlighted to the staff a poster was obtained and placed on the door. Records were examined and discussion with the staff confirmed resident’s healthcare needs are met. District nurses also attend the home to carry out their duties to the residents who do not have nursing care needs. The home’s diary was assessed which showed that appointments to hospital, reviews are recorded and there is a good system in place to remind residents and staff to ensure appointments are not missed. This was confirmed in discussions with residents and a relative wrote “ We are very pleased with the care given etc and are kept well informed as to the outcome of doctor’s visits etc and have generally found out more at the home than from the hospital themselves (if they have been involved in treatment). Most residents were referred to by their first name and this was with the approval of residents and recorded in their care plan. Staff were observed to actively promote independence but residents were given respect and dignity when staff were giving any aspect of care. Residents seen were appropriately dressed with any aids they require, for example glasses and hearing aids. Records showed that doctors, opticians, dentists and chiropodists had visited the residents at Alexandra Care Home. The home will contact the spiritual advisor of the individual resident’s choice and the wishes of the individual resident with regard to their arrangements they want after death are discussed and recorded. It is also recorded if the resident does not want to discuss this matter. Alexandra Care Home DS0000065779.V298369.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 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, and this judgement has been made using the evidence available. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices. Social interaction and the activities programme provided a level of stimulation and interest for residents. 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. 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.V298369.R01.S.doc Version 5.2 Page 15 The home have an activities organiser who works three days a week (8:00am – 4:00pm), 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. Events are planned for example, a summer fayre, strawberry cream tea and a barge trip. The kitchen have been deep cleaned and a new cooker has been ordered A new cook is in post and has been given control of food budget. Residents said that food and meals had improved in recent times and there was more choice and variety. Alexandra Care Home DS0000065779.V298369.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good, and this judgement has been made using the evidence available. 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. Training has taken place on this matter. EVIDENCE: Southern Cross has a complaints policy and procedure, which is clear and accessible to all residents and visitors, this procedure was discussed with the manager, and complaints records checked. Four complaints were recorded since the last Inspection and records show that these had been dealt with promptly and fully investigated with reports available. The questionnaires that were returned showed that service users and relatives (who completed the questionnaire on behalf of the resident) were satisfied with the service and new how to use the complaints procedure. One relative wrote about staff “They always have time to answer our questions and are very concerned and helpful, pleasant and cheerful” and went on to say, “We have had no reason to complain”. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 17 In discussions with residents they stated that they knew how to complain to and to whom. They felt confident in the management that they would take action to resolve the problem/complaint. The home has policies and procedures for adult protection staff spoken with confirm they are aware of these polices and procedures and training sessions have taken place. Staff induction records show that residents’ welfare/rights are discussed, which includes Adult Protection matters. It is the company’s policy for staff to have annual mandatory training, which includes Adult Protection matters for example ten staff had training in Residents Welfare in January 2006. The company have adult protection procedures and the home had a copy of Rotherham Metropolitan Borough Council Social Service Adult Protection Procedures all of which promotes the residents rights to complain and uphold their protection while at Alexandra Care Centre. No Adult Protection investigations have taken place at this service. Alexandra Care Home DS0000065779.V298369.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate, and this judgement has been made using the evidence available. Service users live in a safe well-maintained environment, which was clean and tidy with the exception of two bedrooms. The manager and her staff are working to ensure an environment free from offensive odours. The company are taking action for the re-decoration and the upgrading of the premises. EVIDENCE: The home is in transition in every area of the home. The manager is looking at changing the location of the administration office, nurses office and medication storage. The administration office was used as a storage area and was a health and safety risk. The nurses’ office was also used as a storage area, which was a health and safety risk. There are three lounges, which are light, had a selection of seating available for residents and two of the lounges have access to the garden. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 19 There are two tip and tilt chairs, which were the personal property of previous residents and left to the home. However, there has been no involvement of Occupational Therapy or Physiotherapy assessment that these chairs are suitable for the people who use them. This concern was highlighted to the manager she said that she would request a referral for a full assessment. The dining room (which have French windows giving access to the garden) has been decorated and new curtains have been ordered however the furniture is shabby. Improved lighted has been fitted. New matching crockery and table linen was being purchased. A decision has been made by the company to have a separate nursing area and social care area. Before residents are moved to the separate areas bedrooms will have been decorated and where needed a new carpet and curtains. There is a planned decoration programme for the home with the dining room and some bedrooms have been completed. A number of bedroom carpets have been fitted, curtains and bedding purchased. The home had only one vacuum cleaner and another vacuum cleaner had been purchased. There have been changes to ensure that the home is kept clean. The housekeepers were seen to work extremely hard keeping the home clean however, during a tour of the building two bedrooms had offensive odours. There is a choice of bathing facilities for example, assisted baths and showers with a number of toilets placed around the home. However, a toilet was being used as a storage area, which had a lock on the outside of the door. When this was highlighted to the manager she took immediate action to have the toilet put back into use and the items stored in more appropriate places. The lawns and grounds were well kept with tubs with shrubs and flowering plants. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good, and this judgement has been made using the evidence available. Rotas were examined which showed that staff were working to meet residents care needs and improve their quality of life. The company have recruitment policies and procedures which safeguard and protect residents. There is a training and development plan that shows the staff receive regular training on different aspects of care to meet the changing needs of residents. EVIDENCE: Rotas were examined which showed that there was sufficient staff on duty. Records show that staff had induction and mandatory training was up to date. The training plan showed that the staff had received 3 days paid training per year so that they can keep up to date with care practices without taking up their own time. There are six nurses; sixteen care staff, four domestics, one laundry assistant, two cooks, two kitchen assistants and one handyman. Six care staff members have NVQ level 2 with two having NVQ level 3. The organisation has recruitment policies and procedures, which include equality and diversity for residents who live and for staff who work at Alexandra Care Centre. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 21 Staff files show that these policies and procedures were completed in a correct manner for example two references are obtained and three out of the four staff files assessed had CRB/POVA checks one did not have a CRB check and had only one reference. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 22 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, 33,34,35,36,38 Quality in this outcome area is good, and this judgement has been made using the evidence available. The company and the appointed manager are working to ensure leadership; guidance and direction to staff to ensure residents receive consistent quality care. This results in the health, safety and welfare of residents and staff being promoted and protected. Staff members have not had formal supervision. However, staff supervision session and annual appraisal started in June 2006, which will give guidance and development of the staff group. EVIDENCE: The appointed manager Mrs James has been in post for four weeks. She is experienced in working in a nursing and residential social care setting her qualifications are RGN, Post Graduate in Managements Studies and is an assessor. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 23 She is aware of her responsibilities and aims to run the home in the best interest of service users. Audits have been undertaken. Visits from a member of the company to carry out monthly monitoring visits are undertaken along with further visits to the home to support manager and staff. Residents/Relatives and staff meetings have taken place with minutes taken. Each family have had the opportunity of having a meeting with the manager to express their opinion of the delivery of care. Supervision sessions and appraisal of staff were discussed with the manager and staff that were interviewed these have not taken place. A plan was emailed to the inspector with staff supervision sessions starting later in June 2006. The organisation has sound policies on all areas of care and employment matters and is aware of current legislation. The manager has undertaken audits to ensure adherence to policies and procedures in their day-to-day practice. The appointed manager has taken action to ensure health & safety measures are undertaken and are up to date. For example four staff are pregnant and risk assessments have been undertaken. The service has a Health & Safety Committee. The home has a handyman who is responsible for fire prevention testing measures and testing of water temperature. The home has a fire risk assessment and fire prevention procedures have taken place. Lift and hoists have been serviced and water temperatures are recorded. Accident records were examined and records show that staff complete appropriate documentation. Records show that some residents take responsibility for their own financial matter while for other residents their families deal with all monetary issues. The service provides receipts and receipts are obtained for any financial transactions. All necessary insurance cover is in place to enable it to fulfil any loss or legal liability. Monitoring visits are undertaken on a monthly basis from a representative of the parent company. Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 2 X 3 Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 OP7 Standard Regulation 15, Sch 3(1)(b) Requirement The registered person must ensure that all care plans need to have up to date information and reviewed on a monthly basis. The registered person must undertake assesment for specialised chairs suitability for the individual service user. The registered person must ensure that medcation is stored appropriately. When medication is stored in a fridge it should have a lock. Posters should be on the door where oxygen is stored. Action was taken immediately with the placing of a poster on the door of the area when oxygen was stored. The registered person must ensure that no locks are to be put on the outside of the door on toilets/bathrooms. Toilets and bathrooms must not be used as storage areas. Action was taken immediately DS0000065779.V298369.R01.S.doc Timescale for action 01/09/06 2 OP7 14, Sch 3(1)(a) 01/09/06 3 OP9 13(2), Sch3(3)(i) 05/06/06 4 OP19 13(6) 12(4)(a) 05/06/06 Alexandra Care Home Version 5.2 Page 26 5 OP26 16(2)(j) The registered person must ensure that all bedroom have good odour control The registered person must ensure that each staff member must have 2 references and a CRB check. The registered person must ensure that staff have supervision sessions and annual appraisals. A plan of supervision sessions was sent by email. 05/06/06 6 OP29 Sch2(7) 01/09/06 7 OP36 18, 19 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alexandra Care Home DS0000065779.V298369.R01.S.doc Version 5.2 Page 27 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.V298369.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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