Inspection on 18/01/07 for Alexandra Court

This inspection was carried out on 18th January 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 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 07/03/06

Alexandra Court 18/08/05

Alexandra Court 16/09/04

Alexandra Court 11/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 Catherine Paling Key Unannounced Inspection 10:15 18th January 2007 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 DS0000001410.V324590.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 Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Court Address 333 Spen Lane West Park Leeds LS16 5BS 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) 0113 2743661 0113 2743661 Mr Charles Wray Nelson Mrs Jacinta Jackson Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Alexandra Court is a privately owned care home with 24 registered places for older people. Personal care only is provided with any nursing support provided by the district nursing service. The accommodation is provided over two floors with the first floor being reached by a passenger lift. An extension to the original building has bedrooms with en suite facilities. There is ample provision of communal sanitary facilities throughout the home. Lounge and dining rooms are situated on the ground floor. There are raised patio areas to the rear of the building. The home is situated close to the ring road and is easily accessible by car or public transport. There are numerous community facilities close by including churches, GP, dentists, opticians, shops and a library. Information about the home and the services provided is available to prospective residents in the form of a Statement if Purpose and service user guide. The current range of fees is £385 to £395 per week with £410 per week for a premium room. The provider gave this information in January 2007 as part of the pre-inspection information provided in advance of the inspection. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. More information about the inspection process can be found on our website www.csci.org.uk On some occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. This visit was unannounced and one inspector was at the home from 10:15 until 17:15 on 18th January 2007. The manager was available to assist during the inspection. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by residents were visited. A good proportion of time was spent talking with residents as well as with the manager and her staff. A pre-inspection questionnaire (PIQ) had been completed before the visit to provide additional information about the home. Some survey forms were left at the home providing the opportunity for residents and/or visitors to comment on the home, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. What the service does well: Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 6 The manager and her staff provide stability and continuity for the residents. There is a warm and welcoming atmosphere at the home and recently admitted residents and their families spoke highly of how they had been helped to settle in. The relatives said that they could feel confident that their relative was well looked after at the home. The staff are caring and patient and have clear respect for the dignity and privacy of the residents. They know how to care for the residents and there is good liaison with a range of other healthcare professionals to make sure that healthcare needs are met. There is a clear commitment to training fort he staff to make sure that they have the knowledge to care effectively for the residents. The environment is safe and well maintained. Residents’ rooms are comfortably furnished. What has improved since the last inspection? What they could do better: The manager should work at further developing the individual care plans to make sure that the staff have access to detailed information about all aspects of the care of the residents. The provider must address the issue of the laundry, which is an unacceptable working environment for staff to work in due to the heat and humidity. The provider must record a monthly visit to the home and make the report of that visit available to the CSCI as required under Regulation 26. The provider must make an application for a variation to the conditions of registration for the resident who is outside the registration category. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 7 Requirements and recommendations have been made and appear at the end of this report. 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 Court DS0000001410.V324590.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 Court DS0000001410.V324590.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): 1, 3 and 4. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have enough information to help them make an informed choice about living at the home. All residents have their needs assessed before moving into the home and can be confident that their needs will be met. EVIDENCE: There is a statement of purpose and service user guide available for prospective residents to provide information about the facilities and services at the home. A notice board in the lounge area is used to display other information of interest to residents and their families. For example, a copy of the most recent CSCI report and notes of the most recent residents’ meeting. All the residents have their needs assessed by the manager before they are admitted to the home. A recently admitted resident had some specialist needs Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 10 and the manager had already involved specialist nursing staff to support and guide staff in meeting those needs. Training sessions were also being arranged to make sure that the staff had all the information they needed to understand and meet the needs of this resident. During the inspection it was identified that there was a residents at the home who was outside the category of the home. The manager agreed to apply for a variation to the conditions of registration. Alexandra Court DS0000001410.V324590.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to meet the health and personal care needs of residents. There is good communication among the staff and they are knowledgeable about the individual needs of residents. Residents are treated with dignity and respect. EVIDENCE: A selection of case records were looked at and included recently admitted residents as well as one resident who had been at the home for a number of years. There was evidence of pre-admission assessment and the early involvement of specialist healthcare advice where this was needed. One plan included a life history that had been completed by the family of the resident. The manager said that there were plans to include family histories for all the residents, which would provide a useful insight into the individual. There is a range of risk assessments carried out for all residents and include detailed manual handling and mobility assessments. Staff were supervising Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 12 mobilisation whilst allowing residents time to walk with zimmer frames independently. Staff demonstrated great patience and sensitivity in promoting independence. Risk assessments for nutritional needs and for falls are not completed on admission but after a few weeks when the staff have built up some knowledge of the individual. Residents are weighed monthly and records of these weights are held within the individual files. Residents are registered with a number of local General Practitioners (GPs) and there were detailed records of their visits and any treatment ordered. District nurses provide nursing advice. There are well established and effective working relationships with healthcare professionals making sure that the healthcare needs of residents are met. Staff were very knowledgeable about the needs of the residents. There was a document providing staff with a useful overview of the needs of the individual residents. A more detailed care plan addressed personal hygiene needs and what interventions were needed by staff to support the resident. The manager was aware that the more detailed care planning system was in need of further development and was looking at alternative methods of record keeping. For example, residents with specialist requirements needed more detailed care plans to make sure that all the staff were aware of what observations and staff interventions were needed. It was established that there was one resident at the home outside the homes registration category. The provider must apply for a variation to the conditions of registration. The vast majority staff involved in the administration of medication have completed the appropriate training. Training for the remaining staff is planned for the end of February. Staff are supported by medication procedures and there are safe practices and procedures in place. Any resident who wishes to self medicate is supported to do so after a risk assessment has been done. It was recommended that the blinds should be fitted to the window of the room where medicines are stored, in the interests of security, so that they are not visible from outside the home. There is a clear commitment to and respect of the privacy and dignity of the residents by all the staff. Alexandra Court DS0000001410.V324590.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to be part of the decision making process and make choices about their daily lives. 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 choose when they go to bed and get up as far as possible. They are also encouraged to make their own decisions about their daily lives. There is a programme of activities, which is regularly discussed at the regular residents meetings. On the day of the visit the activities support worker was unwell and had to cancel the weekly quiz. Residents had clearly been looking forward to this and care staff stepped in and organised a lively game of bingo instead. The manager was hoping to utilise a recent legacy left to the residents to improve the availability of trips as well as the range of activities available to residents. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 14 Visitors are welcomed at the home at anytime and residents are able to see their visitors in private. Visitors spoken with were delighted with the care their relative was receiving saying that they were ‘over the moon’ with the home and that they felt confident that their relative was ‘in good hands’. Staff were described as patient and very caring. The resident had settled at the home and felt well looked after. There is a menu programme in place and clear records are kept of the food served to residents. The lunchtime meal looked and smelt appetising and residents enjoyed their food with individual likes and dislikes being taken into account. Residents said that the food was good ‘particularly the sponges’. Residents were given the choice at the evening meal of a light cooked meal or sandwiches with one resident enjoying a can of beer with their sandwiches and crisps. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Procedures are in place to protect residents. EVIDENCE: There is a complaints procedure at the home that is made available to residents and their families. There have not been any recent complaints received at the home. The manager is highly visible in the home and residents and their families find her approachable. It was recommended to the manager that the complaint procedure should be revised to include a timescale for acknowledgement of the complaint as well as the timescale for the final response; the option of approaching the provider as well as contact details of the CSCI. The manager has completed training on adult protection. There are plans to cascade this training to all the staff to further enhance adult protection training included in the National Vocational Qualification (NVQ). There are in-house procedures for staff to follow which correspond with the local authority multi agency procedures for the protection of vulnerable adults. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 16 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, 21, 23, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant, comfortable and well-maintained environment. EVIDENCE: Residents’ bedrooms are of a good size and are comfortably furnished with many residents bringing some personal items with them. All the bedrooms have a washbasin and some have spacious en-suite toilets. There are sufficient communal sanitary facilities situated throughout the home, all of which are a good size to allow for assistance. The communal lounges and dining rooms are on the ground floor and are appropriately furnished. The areas of the home used by residents are well maintained and there is a planned programme of redecoration and refurbishment to maintain the good standard of décor. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 17 The laundry is in an unacceptable condition. There is no ventilation in this internal room and it is not a suitable environment for staff to work in, as it is unacceptably hot and damp. All laundry is done on site and visitors said the standard of laundry was good. Soap dispensers and paper towels have been provided in all the communal areas as part of infection control measures. There is a rolling programme in place to provide radiator covers throughout the home. The manager should risk assess those areas where radiators are without covers to assist her in prioritising the work. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well-trained and competent staff meet the needs of the resident. Residents are protected by robust recruitment procedures. EVIDENCE: The duty rotas indicated that there were sufficient staff to care for the residents. If resident dependency increases the staffing levels are increased accordingly. The care staff are supported by kitchen and domestic staff. There are no dedicated laundry staff and the care staff team manage the laundry within their working hours. There is a clear commitment to training at the home with only one member of the care staff who has not completed an NVQ in care at level 2. Some of the care staff are now keen to progress to NVQ at level 3. All staff have completed first aid training as well as a whole range of mandatory training. The manager makes sure that staff have training in any specialist areas, for example the Parkinson’s liaison nurse has recently visited the home and will be providing some training for staff. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 19 Recruitment practices are satisfactory with all the necessary checks being carried out for staff before they start work at the home. The production of the homes policy on how often to repeat Criminal Record Bureau (CRB) checks for staff was discussed. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 20 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, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 is a qualified nurse and maintains her registration with the Nursing and Midwifery Council (NMC) through regular update. Although regulation requires her to consult with the community nursing service where residents have nursing needs her knowledge and experience is useful when liaising with other healthcare professionals. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 21 The manager has been at the home for a number of years providing stability at the home and she provides clear leadership to the staff. She has completed her NVQ in management at Level 4 and is awaiting certification. Regular staff meetings are held with additional meetings or communication via memo as required. The notes of this contact demonstrate the support and positive leadership style of the manager. Satisfaction surveys are carried out on an annual basis and the results made available to all. Residents meetings are also held and notes of the most recent were displayed in the home. Residents or their families deal with finances in most cases and the home only takes responsibility for a small number of residents’ money. The administrator keeps records for these residents and receipts of all transactions are kept. Health and safety information is displayed throughout the home and a whole range of risk assessments are carried out for the building and working practices. The manager takes responsibility for fire training within the home. She has yet to attend a fire trainer’s course and it was recommended that she access the course as soon as possible. The provider supports the manager and staff and visits the home regularly. He was at the home for a short time on the day of the visit. The provider is required to report monthly to the CSCI on his visits to the home. There have not been any recent reports received at the CSCI. Guidance on these visits was left with the manager to assist the provider. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 22 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 3 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 3 X 3 X 3 3 X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 2 X 3 X X 3 Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 23 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. 1 Standard RQN Regulation Care Standards Act 2000 Section 15 13(3) 26 Requirement The provider must apply for a variation to the conditions of registration for the resident with mental health needs as identified at the inspection. The provider must provide and adequate working environment in the laundry. The provider must produce a report of his regular visits to the home. The report must be made available to the CSCI. Timescale for action 02/04/07 2 3 OP26 OP33 06/08/07 05/03/07 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 OP4 OP7 Good Practice Recommendations The provider should apply for a variation to the conditions of registration for the resident with mental health needs as identified at the inspection. The manager should work at developing the care plans to DS0000001410.V324590.R01.S.doc Version 5.2 Page 24 Alexandra Court 3 4 4 OP9 OP18 OP38 make sure that all aspects of the healthcare needs of residents are detailed for the care staff. Consideration should be given for the fitting of blinds to make sure that medication is not on view form the outside of the building. The planned training in adult protection should take place to make sure that all staff are well informed. The rolling programme to fit radiator covers should continue. Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Alexandra Court DS0000001410.V324590.R01.S.doc Version 5.2 Page 26 - 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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