Inspection on 08/11/07 for Alexandra Care Home

This inspection was carried out on 8th November 2007.

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 18/05/07

Alexandra Care Home 05/06/06

Alexandra Care Home 08/03/06

Alexandra Care Home 04/01/06

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Snydale Care Home

Larchfield Manor

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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 Ramchand Samachetty Key Unannounced Inspection 8th November 2007 09:45 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.V349799.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.V349799.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) Mrs Angela Turner 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.V349799.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 18th May 2007 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 and £ 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 by 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.V349799.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 8 November 2007, starting at 09.45 hours and finishing at 18.00 hours. It was carried out by an inspector and an ‘Expert by Experience’ (a lay person) who attended the home for a period of three hours. There were 45 people in residence at the time of this inspection, 13 of whom had been transferred from a neighbouring home of the Company, due to the summer floods. A new manager, Mrs Angela Turner, was present. All the key national minimum standards for ‘ Care Homes for Older People’ were assessed. The Commission had also undertaken a random inspection of the home on 6 September 2007 to check compliance with the requirements that were made at our inspection of May 2007 and to assess the management arrangements in place at the home. A copy of the report of this random inspection can be obtained from the Commission. The inspection included a tour of the premises, examination of care documents and other records, which included medication, complaints, care records and staff files. We also spoke to twelve people living at the home, three relatives and five members of staff. The care of three people who use the service was examined in some detail and some aspects of care were observed. Feedback on the findings of the inspection, including those of the ‘Expert by Experience’ was given to the registered manager. What the service does well: People who use the service and their relatives said that they were satisfied with the service being provided. They stated that staff were ‘good and friendly’. Social and recreational activities were well organised in consultation with people who use the service, to ensure their preferences were catered for. There was a good staff team, which worked well together to ensure the continuing wellbeing of people living at the home. Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The management of care needs to be further improved. Risks faced by people in their daily activities and action to address them, need to be clearly identified in individual care plans. Improvement is required in the way care provided to individuals is recorded. Recommendations and advice from visiting health care professionals needs to be included in the care plans of the people concerned. Care records of people who use the service must be safely and securely stored to protect privacy and confidentiality. The receipt of medicines at the home must be more appropriately recorded so that proper stock control can be maintained at all times. Appropriate dining furniture, including ‘coffee tables’ need to be provided for the comfort and safety of people who live at the home. An up to date menu should be accessible to people who use the service at all times. Measures are required to ensure that staff can handle food in a more hygienic manner to avoid the spread of infection. The recruitment and selection procedures need to be improved so that appropriate disclosures and references are available before staff start working at the home. Efforts should be made to recruit male care workers to start addressing the gender inequality within the current workforce. The management needs to consider providing more training and guidance to staff on issues regarding the handling and care of people who are wheelchair users and also on the subject of ‘Equality and Diversity’. The management must be more responsive to the need to maintain the safety of equipment and appliances at the home. There is a continuing need to ensure Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 7 that the condition of the passenger lift is improved in order to maintain the comfort and safety of people who use it. 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.V349799.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.V349799.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): 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. Assessments of needs were carried out before people were admitted to the home, in order to make sure that their care needs could be met. EVIDENCE: The care files of three people using the service were checked. They showed that their needs were fully assessed before their admission to the home. The assessments were undertaken by the local care management team and also by the home staff in order to make sure that the needs of people could be met. However, it was noted that in one instance, the placing social worker had sent in a full assessment a few days after the admission of one person who had Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 10 complex needs. The home staff had conducted a preliminary assessment to help them in providing care and support to the individual. The home does not provide an intermediate care service. Alexandra Care Home DS0000065779.V349799.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 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 care and support they were receiving, which they felt was helping them in their daily activities of living. However, the management of risks and the recording of care provided to individuals were not satisfactorily carried out. EVIDENCE: People who use the service and their relatives stated that they were satisfied with the care being provided at the home and felt that individual care needs were being met. They said that staff were “good and friendly”. People using Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 12 the service commented that personal care was provided to them in the privacy of their own bedrooms or in bathrooms. This helped to maintain their privacy and dignity. The care plans of three people using the service were checked. They were based on identified personal and health care needs and on risks that they faced in their daily activities. Actions to be taken to meet individual needs were set out. In a few instances risks faced by individuals were not clearly identified and therefore actions to be taken to manage those risks also lacked clarity and were not always followed. The daily records of care provided were still too generalised and insufficient in detail. They did not always reflect the actual care provided and did not assist in the effective evaluation of care. People using the service said that their health care needs were being met. They had visits from their GPs, opticians and chiropodists. They were referred to the services of other health care professionals by their GPs, as necessary. However, it was noted that in some cases, the outcomes from visits of health care professionals and advice received from them were not included and followed up in care plans. This had led to instances of inadequate care being provided. There was a policy and procedures regarding the management of medicines at the home. One person living at the home was administering his own medicines and had been assessed as being able and safe to do so. The storage, handling and administration of medicines were checked. The storage of medicines was satisfactory. Medicines received at the home were recorded, but the total amount of some items of medicines in stock was not clear, as the carry forward figure was not recorded. It was therefore difficult for staff to keep track of the use of these medicines. Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 13 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 good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People using the service were satisfied with the daily routines and with recreational activities that were available to them, in order to maintain their social life. EVIDENCE: People using the service told us that they were satisfied with the recreational and social activities that were available to them. They said that the activities coordinators who worked at the home made sure that there were enough activities and events, of their choice, to keep them busy. They said that the activity coordinators would discuss with them what they wanted to do and how they wanted to spend their time and then put up a programme of activities and events for groups or individuals. People could also use the monthly ‘Residents Meeting’ to discuss what social activities should be organised. One Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 14 person said that as a lifelong supporter of a football team, she had requested to attend one of its matches and was supported to do so. Commendably, staff had made special arrangements for the match organisers and her team to welcome her. Other activities provided on an individual basis included nail care and hand massage. Group activities included outings, visits to the local shops, museum and library. A programme of activities was displayed on a notice board on the corridor, which kept people informed of the daily events. Some care files contained assessments of the individual’s social care needs and this helped staff to provide appropriate activities, like opportunities for reminiscence and other hobbies. Some people who use the service told us that the daily routines were flexible and they could decide how to organise their time. They said that for example, they were able to choose what time to get up and to retire to bed. They could choose where to have their meals. We spoke to a few relatives and they said that they were always welcomed at the home. They felt that communication between themselves and the staff had improved. They commented positively on the work of the new manager in improving standards at the home. People using the service said that they were satisfied with the meals served at the home. They said that a cooked breakfast was available every morning and that there was usually a choice of the main meal of the day, which was served at lunchtime. They said that the afternoon meal was usually a selection of sandwiches and soup or snacks like ‘beans on toast’ and that biscuits and a drink of tea were offered for supper. On the day of our visit, the dining room was nicely set up for lunch. However, we noted that the gate legs of dining tables were not tall enough to accommodate people who were using wheelchairs and they had difficulty reaching for their food. A menu for the day was displayed but it was outdated. The cook explained that the menu was being reviewed. We noted that people were given a choice of menus and various beverages. The protein part of the day’s main meal consisted of liver and onions and gammon and pineapples, accompanied by seasonal vegetables. An alternative meal was offered to people who chose neither option. We noted that the mid-morning drinks of tea and coffee were served just before lunchtime. Two people observed that the morning drinks were ‘often late and too near lunchtime’. Carers were observed handling and serving biscuits from the biscuit tin to people, with their bare hands. This practice could assist the spread of infection. At lunchtime, carers were observed helping a number of people with cutting up their food and with Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 15 assisting them to eat. Staff explained that special diets were also being offered to some people in order to cater for their dietary needs. Alexandra Care Home DS0000065779.V349799.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Concerns and allegations were responded to promptly and in accordance with the home’s policy and the local adult protection procedures, which made sure that people were listened to and protected from harm. EVIDENCE: A complaints procedure was available to people who use the service and their representatives. A copy of the procedure was included in the service user guide and a copy was given to each person living at the home, to inform them of how they could raise their concerns if something was not right for them. Complaints records showed that the home had received three complaints in the last six months. They had been investigated and satisfactorily completed. Two of the complaints had been fully upheld and the third one had been partially upheld. The manager stated that as a result of the complaints, action had been taken to improve the service. The complainants had been informed of the outcomes, with which they were satisfied. Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 17 There was an adult safeguarding policy to guide staff on the prevention of abuse and on the procedures to be observed in reporting any allegations of abuse or harm within the home. Staff we spoke to said that they had received training on issues of adult safeguarding and were aware of the relevant policy and procedures. The manager stated that a previous allegation of adult abuse, which was outstanding from the last inspection, had been resolved with the assistance of the local adult safeguarding team. However, the manager stated that a more recent allegation had been referred to the adult safeguarding team and was currently being investigated. Alexandra Care Home DS0000065779.V349799.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 overall standard of accommodation. However, inadequate and inappropriate furniture in the communal areas caused inconvenience to people living at the home and affected their enjoyment of the place. EVIDENCE: People living at the home were satisfied with the standard of accommodation. They said the home was clean and comfortable. A few people said they were Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 19 encouraged to personalise their bedrooms with some of their own furniture and other memorabilia. We looked round some parts of the home, in the company of the manager. She stated that a refurbishment plan was in place and was being implemented. It included further upgrading and decoration of bedrooms and bathrooms, to make them more ‘homely’. The home was well maintained, well decorated and clean. The corridors and lounges had been fitted with new carpets and this made the home pleasant. We noted that there was a lack of ‘coffee tables’ in the lounges and because of this, some people had to hold their cups and saucers on their lap. This appeared to be an inconvenience to the people concerned, in particular those who were frailer. The door in one of the dining rooms was difficult to close and we observed it being blown open by the wind. Fire doors in the laundry and kitchen had been fitted with automatic door releases to ensure they could be used safely. We noted that an unlocked cupboard situated in the downstairs lounge, in the residential unit, was being used to store care files of people living at the home. This practice infringes peoples’ privacy and confidentiality and also the use of their communal space. We viewed a few bedrooms with the permission of their occupants. They were found to be well decorated and well furnished and the people who live in them said that they were ‘very happy’ with their personal accommodation. The surrounding grounds appeared well maintained for the time of the year and were tidy. Alexandra Care Home DS0000065779.V349799.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. 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. Staff performance, in particular, for those working at night, was not adequately monitored and this led to some poor care practices. The recruitment and selection procedures were not robustly implemented and these could lead to inappropriate staff being recruited. EVIDENCE: The home is registered to care for up to 47 older adults. On the day of this visit, there were 45 people living at the home. Sixteen of them were from a neighbouring home of the Company, which had been affected by the summer floods. They had moved to this home together with some members of staff. Thirty-two people required both nursing and personal care and thirteen required personal care only. There were two first level nurses and six carers on the morning shift and two first level nurses and five carers on the afternoon shift. One first level nurse and four carers were scheduled to work at night. Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 21 The registered manager worked a regular day shift, which was supernumerary, to the staffing hours. The care team was supported by two activities coordinators. There appeared to be sufficient domestic and kitchen staff on duty. The duty rota showed that this level of staffing was consistently maintained at the current occupancy level. In discussion, people who live at the home and their relatives commented that there were sufficient staff to provide the care and support needed. However, a number of people who use the service commented negatively on the care provided during the night. They stated that ‘night staff took a long time to answer a call’ and ‘they did not leave the call buttons within their reach’. The records of two members of staff recently recruited were checked. They included their completed application forms, two written references and the outcomes of their ‘Pova First’ checks. In one instance, the deputy manager of the home itself had provided a reference for an external applicant. Both new care workers started working at the home before their disclosures were received from the Criminal Records Bureau (CRB). The manager explained that they had both received induction and were working under supervision. However, these recruitment practices tend to reduce the effectiveness of the home’s recruitment and selection procedures and could put people who use the service at risk. Although the recruitment and selection procedures included an equal opportunities policy, we noted that all the care workers at the home were female. This could affect the way care is provided to men who use the service, in particular their personal care. However, members of staff belonged to a mix of ethnic backgrounds. We spoke to three members of staff. They stated that they were receiving on going training in a number of areas. These included refresher courses in moving and handling, food hygiene and first-aid. However, there was no evidence that training had been provided on issues relating to ‘Equality and Diversity’. One first level nurse had received training on ‘Tissue Viability’ and was helping to train other staff on the same subject. Thirteen out of twenty-six care staff had achieved their ‘National Vocational Qualification’ (NVQ) level 2 in Direct Care. Alexandra Care Home DS0000065779.V349799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 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. The management of the home has improved. However, there were still shortfalls in some health and safety issues, like the moving and handling of people and the use and maintenance of equipment. EVIDENCE: The new registered manager is a first level nurse with experience of working in residential care for older adults. She holds a certificate in Management studies, Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 23 which she states is an equivalent of the ‘National Vocational Qualification’ level 4 in management. In discussion, staff said that they were satisfied with the way the new manager was running the home. They felt that they were working well as one team and that they were well supported in undertaking their tasks. This was helping them to provide a better standard of care. A number of people who live at the home and their relatives also told us that in their view the management of the home had improved and as a result, there was better communication and a more pleasant atmosphere. We spoke to some members of staff and they confirmed that they were receiving regular supervision from the manager and other senior staff. The manager stated that she had put in place a programme of supervision for all staff and staff records showed that it was being followed. We looked at quality assurance methods that were in place to evaluate and improve service provision. The manager stated that she had use of a number of quality audits, which she undertook regularly. These included audits of care plans, medicines administration, accidents and equipment. There was evidence that these audits were carried out. However, the outcomes of these audits and any remedial actions taken to address them were not clear. We noted that ‘Residents Meetings’ had been re-established and were being held on a monthly basis. A number of people who live at the home told us that they found the meetings ‘helpful and interesting’. The manager confirmed that a ‘Residents’ Satisfaction Survey’ would be organised in due course. The manager also stated that regular staff meetings were being held in order to improve communication and in turn, the standard of care being provided. Arrangements were in place to support people living at the home with the management of their personal allowances. All financial transactions undertaken on behalf of the people concerned were appropriately recorded, witnessed and signed for and receipts were kept. These procedures ensured that their financial interest was being safeguarded. Accounts checked were in balance. We noted that a sum of money was made available for people who may need it outside office hours. In discussion, staff said that they were aware of the home’s health and safety procedures. A few said they had received training on health and safety issues, but felt they needed refresher courses to keep them up to date. We observed a few instances where staff failed to apply the brakes on wheelchairs once they had finished attending to the needs of people who were using Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 24 wheelchairs. These practices could result in harming people who need help and support in their daily activities. We noted that fire safety had been improved by the provision of automatic fire door releases to the laundry and kitchen area. However, there had been no attempt to improve the condition of the passenger lift since our inspection of May 2007. It was still poorly lit and remedial work on other defects had not yet been undertaken. The manager explained that the repair work had been requested and would be carried out in due course. The manager was advised to conduct a risk assessment for the use of the lift in the meantime. Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 25 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 26 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 Regulation 14 Requirement The outcomes of visits by health care professionals and any specific advice given regarding the care of individuals must be appropriately included in their care plans and followed as necessary. Risks faced by people who use the service must be clearly identified and action to manage those risks must be clearly set out in their care plans. Medicines received at the home must be appropriately recorded to allow for proper stock control. (Previous timescale of 16/07/07 not met) Dining tables must be of appropriate dimension to allow wheelchair users to sit at them for their meals. The door in one of the dining rooms, as identified, must be repaired or replaced. Care files of people who use the service must be kept safely and securely and away from communal areas, to protect their DS0000065779.V349799.R01.S.doc Timescale for action 07/02/08 2 OP7 14 07/02/08 3 OP9 13 07/02/08 4 OP15 12, 16 07/02/08 5 6 OP19 OP19 23 12, 23 07/02/08 07/02/08 Alexandra Care Home Version 5.2 Page 27 7 OP28 13 8 OP29 19 privacy and confidentiality. A call alarm system must be made available to each person using the service, at all times so that they can summon help as needed. The recruitment and selection procedures must be improved to make sure that appropriate disclosures and references are sought and obtained before staff start working at the home, in order to protect vulnerable people. The identified remedial work required for the passenger lift must be carried out as a matter of urgency. In the mean time a risk assessment must be put in place to ensure the comfort and safety of people who use it. (Previous timescale of 16/07/07 not met). Appropriate training and guidance must be given to care staff on how to handle and care for people who are wheelchair users. 07/02/08 07/02/08 9 OP38 13 07/02/08 10 OP38 13 07/02/08 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 OP7 OP15 Good Practice Recommendations Records of care provided should be improved to reflect sufficient detail to help with continuity and evaluation of care. Up to date menus should be made available to people who live at the home and should be appropriately displayed in the home. DS0000065779.V349799.R01.S.doc Version 5.2 Page 28 Alexandra Care Home 3 4 5 OP15 OP15 OP29 6 OP30 Measures should be taken to ensure that all food is handled in a hygienic way to prevent the spread of infection. Sufficient ‘coffee tables’ should be provided to make sure that people can enjoy their drinks and snacks in comfort and safety, whilst they are in the lounges. Consideration should be given, in line with equal opportunities policy, to the selection and appointment of male care staff, for the benefit of people who use the service. Staff training and development should include issues regarding ‘Equality and Diversity’. Alexandra Care Home DS0000065779.V349799.R01.S.doc Version 5.2 Page 29 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. 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