Inspection on 14/03/06 for Alexandra Court

This inspection was carried out on 14th March 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 Court 21/01/10

Alexandra Court 10/12/08

Alexandra Court 01/11/06

Alexandra Court 06/12/05

Alexandra Court 02/02/05

Alexandra Court 19/10/04

Similar services:

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Chirnside House

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

CARE HOMES FOR OLDER PEOPLE Alexandra Court Howard Street Pemberton Wigan Lancashire WN5 8BD Lead Inspector Bernard Tracey Unannounced Inspection 14th March 2006 09:30 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 Court DS0000005666.V268842.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 Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alexandra Court Address Howard Street Pemberton Wigan Lancashire WN5 8BD 01942 215555 01942 738753 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) Mr Keith Lowe Judith Melling Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (6) of places Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include:up to 40 service users in the category of OP (Older Persons) up to 6 service users in the category of PD (Physical Disabilities under 65 years of age) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6th December 2005 2. Date of last inspection Brief Description of the Service: Alexandra Court is a care home situated within the Pemberton area and is close to local shops and other facilities nearby. Public transport is easily accessible. Access to the motorway network is also nearby. The home is purpose built and all personal accommodation is provided in single rooms each with an en suite facility. Accommodation is provided on two floors with a passenger lift allowing access to the upper floor. Alexandra Court provides Intermediate Care that has been commissioned by the Primary Care Trust and Social Services Department. Care arrangements can be used to facilitate earlier discharge from hospital following an acute episode of illness; alternatively, it can provide care to prevent admission to hospital for people who have a short term episode of ill health, which does not require specialist medical intervention. All admissions have a time-limited stay, maximum being six weeks. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by the Lead Inspector for the home and took place over three hours on the 14th March 2006. This is the second statutory inspection for the year and should be read in conjunction with the first inspection carried out on 6th December 2005 to give an overview of all the standards to be assessed within this period. Observations were made of the care provided and four service users talked about their personal experiences of life for them in the home. Four members of staff, the manager and four relatives were spoken with during the course of the inspection. The inspector looked at the records of satisfaction questionnaires and talked with the service users to gain their opinion of the home and particularly what they thought of the food provided. The questionnaires asked what people thought of the care and services provided by the home. What the service does well: The qualified nurses, physiotherapists, occupational therapists and care staff were extremely good at providing the specialised care needed by service users to enable them to return home. The staff make sure that all the necessary equipment needed for their care was available. Staff were said to carry out their duties “in a caring and thoughtful way with unfailing good humour.” Comments from a relative were “the staff are superb”, “I have every confidence in them”, “they keep me informed of any changes and how my aunty is progressing”. One service user said “the care has been exemplary – I have had a very pleasant stay” Meals and mealtimes were considered to be an important part of the service users’ day. The dining room was a nice place to sit, eat and meet with other service users. The service users said that they really enjoyed their meals. They were satisfied with the choice of meals and the way they were cooked and served. Comments such as “Im very happy with my treatment here” were made to the Inspector. Comments from a relative were “the staff are superb”, “I have every confidence in them”, “they keep me informed of any changes”. Alexandra Court DS0000005666.V268842.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 Court DS0000005666.V268842.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 Court DS0000005666.V268842.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): The key standards were examined at the last inspection. A member of the Primary Care Trust assesses residents before admission to the home to ensure the placement in a rehabilitation unit is appropriate to their needs. Residents are provided with clear information regarding the admission and assessment procedures to ensure they are informed how their care needs are to be met. EVIDENCE: The key standards were examined at the last inspection on the 6th December 2005. All of the key standards were met Alexandra Court DS0000005666.V268842.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): The key standards were examined at the last inspection. Resident’s welfare is closely monitored to ensure that all health needs were met. EVIDENCE: The key standards were examined at the last inspection on the 6th December 2005. All of the key standards were met. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 10 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 There are some opportunities for service users to participate in activities during their stay, so their social care needs are fulfilled. There is flexible visiting on the unit and visitors to the unit are welcomed. The catering arrangements are adequate, providing an appropriate choice of meals to meet individual service users needs. EVIDENCE: Leisure and recreational activities are not provided as a dedicated part of the service due to the content of the therapy provision and the rehabilitation process. Future social needs are discussed, concentrating on appropriate support and exploring possible day care links on the service users return to home. Service users spoken with at the inspection confirmed that they were quite satisfied with the level of informal activities occurring in the home but at times it was “difficult to fill in the time between meals”. Service users are encouraged to maintain contact with their family and friends as well as accessing facilities in the local community. Service users are able to Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 11 receive visitors and meet with them in private. Visitors are made very welcome and this was confirmed in conversation with four visitors on the day of the inspection. Service users handle their own finances. Records of food provided to residents confirmed that all receive a varied and nutritious diet. The meals were usually taken in the main dining room; staff then served individual residents at their table. The inspector-spent time talking with three service users to gain their views of the catering arrangements. Service users said that the staff had been made aware of their appetites and preferences and felt that their meals met their needs and were presented in an attractive and appetizing manner. There was a choice of main courses and the chefs confirmed that further choices were available from the kitchen. Service users said that they “really liked the food”. Snacks, such as toast or cheese and biscuits are available for staff to access during the period when the main kitchen is closed Alexandra Court DS0000005666.V268842.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): The key standards were examined at the last inspection. Procedures for dealing with complaints and reporting abuse were satisfactory ensuring people are adequately protected. EVIDENCE: The key standards were examined at the last inspection on the 6th December 2005. All of the key standards were met. Alexandra Court DS0000005666.V268842.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): The key standards were examined at the last inspection. The home has a planned maintenance and renewal programme for the redecoration and refurbishment of the home to ensure residents live in a comfortable, homely and safe environment. EVIDENCE: The key standards were examined at the last inspection on the 6th December 2005. All of the key standards were met. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 14 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): The key standards were examined at the last inspection. Staff are well trained to ensure they have the competencies to meet residents needs. There is sufficient staff to meet the needs of residents. The homes recruitment procedures are robust and these provide safeguards for the protection of residents. EVIDENCE: The key standards were examined at the last inspection on the 6th December 2005. All of the key standards were met. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 15 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): 3132 33 35 36 38 The manager is supported by the senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of service users, staff and relatives. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 16 EVIDENCE: The manager is a Registered General Nurse with several years experience working with the elderly in a care home setting. The manager is responsible for another home on the same site as the care home. She is aware of her responsibilities both as a nurse and as a manager. There are clear lines of accountability within the home. The manager and deputy manager are currently undertaking management training. Staff interviewed on this Inspection confirmed that the Registered Manager is able to communicate a clear sense of direction and leadership and that her approach to running the home is open and transparent. Staff felt that they could approach the Registered Manager and felt supported both in their daily activities, and in developing themselves in their work environment. One service user described the manager as “Very approachable, understanding and listens to your queries” Feedback is sought from the service users and relatives through a system of satisfaction questionnaires. A selection of these questionnaires was examined during the inspection and in the main was found to be complimentary. The manager collates the comments on a quarterly basis and the results are presented to the Clinical Governance meeting held with the Primary Care Trust. As part of the provision of Intermediate care the home also audits the service in conjunction with the Primary Care Trust through the means of a quality questionnaire. Policies and procedures are up dated and reviewed as an ongoing practice and action is taken to ensure the requirements of the inspection reports are met. The home completes in-house audits of its service on a monthly basis, and the Quality and Training Coordinator competently oversee this. The home has recently been awarded 4 stars by the Residential and Domiciliary Benchmarking (RDB) an external quality monitoring service. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. Staff agreed that they are able to express ideas, criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. There is evidence of ongoing training for all members of staff with a comprehensive induction programme covering all aspects of service user care. The registered person ensures that the employment policies and procedures and its induction and training process are put into practice. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 17 Staff supervision files show that individuals receive formal supervision with their line managers on a regular basis and staff appraisals are also completed each year. Records required for the protection of service users and the running of the business are in place, reviewed and up dated as required. Service users and the relatives spoken with during the inspection were aware that they can access their personal records as and when they wish to do so. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 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 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The home should ensure that sufficient consideration is given to the social needs of the service users. Alexandra Court DS0000005666.V268842.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Court DS0000005666.V268842.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. 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