Inspection on 08/03/06 for Alexandra Care Home

This inspection was carried out on 8th March 2006.

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 18/05/07

Alexandra Care Home 05/06/06

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 Janet McBride Unannounced Inspection 8th March 2006 14:15 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.V285981.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.V285981.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.V285981.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 4th January 2006 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.V285981.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Alexandra Nursing Home, on the 8th March 2006, commencing at 14:15 and finished at 17:15. This was the home second Inspection since Ashbourne (Eaton) Ltd has become the proprietor of Alexandra Nursing Home, however the home as been taken over again by Southern Cross (but is still registered as Ashbourne Eaton) As this was the second sale of the service in a short time the Inspector was interested in how these changes affected the residents and relatives. Most of the key standards were assessed in the unannounced inspection that was conducted early in the year, although it may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at a number of standards, a chosen number of documents, sampling of records, partially tour of the premises and indirect observation of staff interaction with residents, this Inspection also included discussions with management, and comments from residents about the changes in ownership, some stated no changes in life within the home, and felt it helped by keeping the same staff. 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: In respect of the service and care delivery the home continues to provide a good quality provision and is managed by a manager who ensures leadership, guidance and direction to staff and that residents receive consistent care. Those residents spoken to confirm they were happy with care they received, and satisfaction with the service. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra Care Home DS0000065779.V285981.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.V285981.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): Key standards assessed at the last Inspection and met. EVIDENCE: Alexandra Care Home DS0000065779.V285981.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): 78 Resident’s health care needs are fully met, including support from health professionals. Care plans contain detailed information to enable staff to deliver each resident individual care needs. EVIDENCE: The manager audits care plans on a monthly basis, which were available to examine. Two care plans were checked in detail and crossed referenced with medication and any other health care information, also discussed with the clinical manager. Each care plan contained full assessment of care needs prior to admission; from this the home formulated individual care needs, and current objectives for health and personal care, including risk assessment. Some care plans had been signed by either the resident or there relative to show that they had been involved in care planning. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 10 All residents are registered with GP and have access to health care services, including specialist services if required for example some residents had been referred to dietitians, phyiso and CPN services. The home completes audits on various care needs; one of these is pressure care, and records show involvement of tissue viability nurse when required. Alexandra Care Home DS0000065779.V285981.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): 15 Dietary needs of residents are well catered for with a balanced and varied selection of food available. EVIDENCE: All these standards were assessed on the last Inspection and met with the exception of some issues being raised regarding equipment in the all of which as been addressed. Care plans show that all residents have nutritional assessment completed and that dieticians are used when needed. Residents spoken to state that food at the home is good and that they always have a choice. Mealtimes are unhurried and staff ensured that residents who need assistance, that this is given on an individually basis. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 12 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): Key standards assessed on the last Inspection and met. EVIDENCE: The complaints procedure was discussed with the registered manager, which remains the same, and records checked, show that the home have had no complaints since the last Inspection. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 13 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 24 26 The home is clean, tidy and safe but further equipment is required to ensure that domestic staff continues to maintain the environmental standards within the home. EVIDENCE: Redecoration programme continues, and changes to the lounge and dining areas as made a big improved to the communal areas of the home, but the dining room carpet is still waiting to be fitted; otherwise the home was clean and tidy. Tour of the bedrooms on the last Inspection found them to be clean and comfortable, any issues raised have been addressed with the exception of the home providing adjustable beds for nursing residents, this was discussed with the manager who stated that residents had been assessed and those that require this type of bed will be purchased and phased in from mid April 2006. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 14 Laundry facilities are satisfactory but the home needs colour coded skips for dirty laundry to ensure infection control procedures are followed. The home has domestic staff in appropriate numbers but on the last Inspection some issues was raised with regard to equipment that domestic staff need to ensure that environmental standards are maintained, for example the home only as one industrial cleaner, and one domestic trolley, therefore the domestic staff can not clean all floors together, this does not seem adequate for a home this size and on three floors, this still requires addressing. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 15 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): 28 29 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: Training was discussed on the last Inspection and requirements were made regarding induction and foundation training for new staff, no evidence was found that the company provide induction and foundation training that meets NTO specifications, and this remains outstanding. Care staff within the home can access NVQ training and this was discussed with the manager, a number of care staff has completed their NVQ level 2, and other members of staff are on courses to achieve this, therefore the home are on the way to achieve 50 of staff being NVQ trained. Recruitment policies and practice is good, and meets this standard. Records show that the registered person operates a thorough recruitment procedure based on equal opportunities; references, CRB and POVA checks are carried out ensuring the protection of residents. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 16 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 36 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: All of the key standards were assessed on the last Inspection and met, with the exception of the manager completing his NVQ level 4 in management. The manager is competent and experienced to run the home, being a qualified nurse and vast experience within the NHS and private sector, to continue with is own development he his completing his NVQ level 4 in management. Supervision was discussion with the manager, who stated that staff receiving formal supervision but not always on a regular basis. The manager confirmed that he receives formal supervision from his regional manager. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X 3 X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X X Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 18 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 OP26 Regulation 23(2) (c) Requirement Laundry facilities must have colour coded skips for infection control. (Timescale of 28/02/06 not met) Domestic facilities must ensure that domestic staff has the equipment to complete tasks with regard to industrial cleaner and domestic trolley. (Timescale of 28/02/06 not met) Training; The Registered provider must ensure that new Staff receives induction and foundation training to NTO specification to equip them to fulfil the aims of the home, and meet service users needs. (Timescale of 31/03/06 not met) Timescale for action 30/04/06 2 OP26 23(2)(c) 30/04/06 3 OP30 18(1)(c) 30/04/06 Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 19 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. Refer to Standard OP28 OP31 Good Practice Recommendations 50 of care staff must be trained to NVQ Level 2 or equivalent. The registered manager must achieve NVQ 4 in management. Alexandra Care Home DS0000065779.V285981.R01.S.doc Version 5.1 Page 20 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.V285981.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!