Inspection on 18/08/05 for Alexandra Court

This inspection was carried out on 18th August 2005.

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 08/01/09

Alexandra Court 18/01/07

Alexandra Court 07/03/06

Alexandra Court 16/09/04

Alexandra Court 11/06/04

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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 Court 333 Spen Lane West Park Leeds LS16 5BS Lead Inspector Kathleen Firth Announced 10.30am 18 August 2005 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 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 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Alexandra Court Address 333 Spen Lane West Park Leeds LS16 5BS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2743661 0113 2179555 Mr Charles Wray Nelson Mrs Jacinta Jackson Care home 24 Category(ies) of Old Age (24) registration, with number of places Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection September 2004 Brief Description of the Service: Alexandra Court is privately owned and offers care and accommodation for up to twenty four older people. The accommodation is over two floors with the first floor being reached by a passenger lift. Some rooms are in an extension and have en-suite facilities. The home is situated close to the ring road at Horsforth and is easily accessed by car or public transport. There are numerous community facilities close by including churches, GP, dentists, opticians, shops and a library. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over 6.25 hours by one inspector on Thursday August 18th 2005. The inspector toured the building, spoke with ten residents, five staff, the owner, manager and four visitors, examined residents’ records including care plans, menus, staff rosters and the information leaflet. Everyone was very helpful throughout the inspection and were happy to join in the process. What the service does well: Each resident has a very comprehensive care plan in place with their needs clearly identified. The tasks required to meet the residents’ needs are recorded along with any specific instructions. Allergies are clearly identifiable in the care plans. Communication within the home and with relatives is very good and meetings are held with staff and residents. The local community nurse said that she is happy to support the care staff and is available to offer advice when required. A Physiotherapist was visiting one lady to offer specialised advice on movement and handling and to pass on instructions about exercise. Residents spoken to confirmed that they are able to get up and go to bed at the times they choose and are able to have visits from their family and friends with no restrictions. All of the residents said that they feel respected by staff and that they are well looked after. One lady said that the food is wonderful and that staff do as much as they can for the residents. The residents are able to sit outside in safety and this is something that they appreciate. People spoken to said that they would be happy to approach the manager or staff if they have any concerns or worries. One relative spoke to the manager during the inspection and was given feedback about her mother’s health. She said that the home always kept her informed of any change and she is very happy to go on holiday knowing that her mother is in good hands. All of the residents spoken to said that they were happy with the activities offered at the home and that they had enough to do. There is a commitment to training at the home and staff confirmed that they are encouraged to work towards NVQ (National Vocational Qualifications). All staff at the home have achieved or are working on NVQ including the domestic team. The manager is working on the Registered Manager’s award and hopes to complete this in the near future. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 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 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 5, 6 People are able to make an informed decision about the home from the written and verbal information they receive and what they see when visiting the home. EVIDENCE: A brochure containing all relevant information about the home and the services it provides is given to all people thinking about coming to live at the home. The manager offers people the opportunity to read the last CSCI report about the home and informs them where they can obtain copies of past reports. This information helps them to make an informed choice about the home. Prospective residents have an assessment of need carried out by the manager prior to the home agreeing their admission. Any information that social services have is shared with the staff at the home including any need and risk assessments. Future residents are all given the opportunity to visit the home and stay for a meal with the people living there. They also get chance to talk to staff and residents whilst they are there. If people are coming from outside the area Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 9 they are able to stay overnight or for a weekend if this is appropriate. People are initially admitted for four weeks before the place is made permanent. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, 10 Staff are aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: Care plans looked at contained the needs of the residents and what tasks are required to be done in order for staff to meet these needs. The plans are clear, concise, easily understood and contained healthcare, social and religious needs. Allergies are recorded on the care plans, as are any healthcare professional visits with the outcome of the visit and any actions needed. Evidence was seen that the residents are included in the drawing up of the care plans and that they are reviewed on a regular basis. Residents said that they are treated with respect and evidence of this was seen at the inspection. There was evidence that plans are in place for residents to ensure regular visits by/to dentists, opticians and chiropodists. The manager said that staff at the home enjoy a good working relationship with the local healthcare teams who offer excellent support. People keep their own GP where possible and are given information about changing their doctor where required. Some residents receive support from CPNs and one attends day care Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 11 at the local Psychiatric unit. The manager was observed giving information to a daughter of a resident following a GP visit. The relative confirmed that her mother receives excellent care at the home and she is always kept informed of any change in her condition. Residents are weighed on admission and then on a monthly basis with any losses or gains noted. Two residents look after their own medication and have a lockable cupboard in their room for storage. Their ability to continue to manage their medicines is reviewed on a regular basis. The home has a comprehensive medication policy in place to manage the remaining medication. Medication was seen to be stored correctly and all records were appropriately maintained. The home has a good relationship with the local pharmacy, which offers good support to them. Staff were seen to give out medication in a correct manner. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15 Residents are encouraged to be part of the decision making process and make choices about their lifestyle. They are supported to maintain contact with family and friends and visitors are welcomed at the home. A good, varied and nutritious diet taking into account individual choices is provided at the home. EVIDENCE: Residents are able to decide if they want to be checked at night and sign to say they do not want this to be done. They are able to go to bed and get up at the times of their choice as far as possible. Residents spoken to said that they feel able to speak to the manager or staff if they are unhappy or concerned about anything. There is a designated smoking area in the home and everyone is made aware of this before coming to the home to live. The residents spoken to confirmed that the meals served at the home are very good and there is always a choice offered. The dining room is a very pleasant area and offers everyone sufficient space to sit and eat their meals in comfort. The meal served at the time of the inspection was seen to be nicely presented and nutritious in content. Meals were dished up for every individual with the person serving naming the resident it was for. This ensures that people receive the food they like and the amount that suits them. Staff were seen to be offering the amount of support required to residents to ensure that they were able to enjoy their meal. Families are able to have meals with their Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 13 relative if they so choose. Meals can be eaten in their own rooms if the residents prefer to do so. The home has an activities organiser one day per week and evidence was seen of the work she does with the residents. Small group trips out are arranged and entertainers come into the home. The residents spoken to said they were happy with the amount and type of activities offered at the home. One lady said they enjoy playing cards and dominoes as well as just sitting and talking. The quiz that was held during the inspection was very popular. Residents are able to go out with family and friends if this is agreed in their care plans. A Church of England service is held on a monthly basis and is well attended. Arrangements are in place for the Roman Catholics to receive Communion. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16, 17, 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents have their rights protected and are protected from abuse. EVIDENCE: The appropriate polices and procedures are in place and the manager confirmed that staff have had Adult Protection Training. A copy of the complaints procedure is on display in the hallway. Residents said that they are able to speak to the manager and the staff if they have any concerns or worries. Residents confirmed that they are able to vote in local and national elections. At the last election some people went to the polling station and others used the postal system to register their vote. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 23, 24, 26 The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toileting facilities. EVIDENCE: The home is decorated and furnished to a good standard throughout and evidence was seen that a maintenance programme is in place. There is a call system in all areas of the home that staff and residents can use to summon help. A decking area outside the lounge/dining area offers a comfortable space for the residents to sit in the fresh air. This area is very popular in the good weather and residents were using it at the time of the inspection. All of the residents are able to access this outside area easily. Residents were wearing sun hats, as the day was very sunny and warm. The bedrooms are of a good size, nicely furnished and made personal by residents bringing their own things with them. All of the rooms have a pleasant outlook and the residents are happy with their accommodation. They were able to confirm that staff knock on their door before entering the room. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 16 There are sufficient toilets near to the communal rooms and the bedrooms without en-suite facilities to ensure the residents have easy access. They are all big enough to allow people easy access if using a walking aid or wheelchair. Soap and towels were available in all of the toilets. Assisted bathing facilities are available at the home and these are spacious to ensure safety of residents and staff. The bathrooms and toilets can be locked by the service users but can be opened if there is an emergency. No hazards were seen that could cause problems for residents, visitors or staff. The home was clean and tidy throughout and no unpleasant odours were present. One of the housekeepers has an NVQ Level 1 and 2 in housekeeping. The laundry is sufficient to meet the needs of the residents and has a sluice facility. It is sited well away from the kitchen and communal areas. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Residents are supported and protected by recruitment procedures in place. Staffing numbers and skill mix ensure that the residents’ needs can be met. EVIDENCE: The staff numbers were appropriate at the time of the inspection and residents and staff were able to confirm that this was the normal way of working. The staff rosters viewed confirmed the numbers of staff on duty at any given time. Staff cover shifts for each other and the home has its own bank, as the manager is reluctant to employ agency staff. Recruitment is carried out to comply with equal opportunities and two written references; CRB (Criminal Records Bureau), POVA (Protection of Vulnerable Adults), Visa and work permits checks are required before staff begin work at the home. People are asked to bring ID with them when they attend for interview and notes made at the interview are kept. Training is seen as very important at the home with all staff including the domestic team having or working on NVQ at different levels. All staff have the Food Hygiene certificate and are trained in first aid. Any staff who deal with medication have received training in order to do so. Staff meetings are held each quarter with at least two weeks notice given. An agenda is available and staff are able to add any of their own items to this. Minutes are taken and people unable to attend are able to see these. If there are any problems or issues needing to be addressed between meetings an extra one is held. Talking to staff there appeared to be a good team spirit and staff said that they Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 18 all offer support to each other. Most of the staff have worked at the home for a long period. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years of experience working in residential care for older people and is a qualified nurse. She is working towards the Registered Manager’s award. Residents’ meetings are held usually at the change of the seasons. They normally focus on the menus but residents are free to raise any other matters if they wish. Staff all said that they receive excellent support from the manager and she is happy to speak to them if they have any concerns/ideas. Residents or their families deal with finances in most cases and the home only takes responsibility for a small number of people’s monies. The record for these were seen to be correctly maintained and all money is kept locked in the Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 20 safe. There is an awareness of Health and Safety at the home and although the manager takes overall responsibility for this all staff are trained in this area. Residents’ records were found to be up to date and detailed and are stored in locked cabinets in accordance with the 1998 Data Protection Act. Residents can have access to their record if they so wish. Fire bells are tested weekly and fire training held twice per year. The manager regularly works with her staff providing the everyday care for the residents. Supervision sessions are set up but the manager said that these do not always happen due to time restraints. Some ideas were discussed as to how this situation could be rectified. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 3 3 2 3 3 Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 22 NO 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. Standard Regulation Requirement There are no requirements from this inspection. 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 Good Practice Recommendations There are no recommendations from this inspection. Alexandra Court 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 20050818 J52 S1410 Alexander Court V189008 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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