Inspection on 07/03/06 for Alexandra Court

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 18/08/05

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 Valerie Francis Unannounced Inspection 7th March 2006 10:00 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.V284032.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 DS0000001410.V284032.R01.S.doc Version 5.1 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 274 3661 0113 274 3661 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.V284032.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 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 DS0000001410.V284032.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 30 March 2005. There have been no further inspections until this unannounced visit. The people who live in the home prefer the term resident, and this is the term that will be used throughout this report. The purpose of this inspection was to gain an overview of the care, services and facilities provided. During the inspection some records were looked at, some parts of the home were seen, such as bedrooms, lounges and bathrooms; care staff were seen carrying out their work; conversations were held with the manager (who facilitated in the inspection process), 3 members of staff, two relatives, and high proportion of residents. Survey cards were left at the home for residents, relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI), several relatives and residents responded. These cards provide an opportunity for people to share their views of the service with the CSCI. Comments are included in the body of this report without revealing the identity of those who replied What the service does well: What has improved since the last inspection? No requirements or recommendations made at the last inspection. From observation, and from discussion with manager staff and residents, it was clear that there is good commitment to provide residents with a good standard of Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 6 care, so therefore there are continual changes to improve service and the delivery of care. 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 DS0000001410.V284032.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 DS0000001410.V284032.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): 2 & 4. Each person knows what to expect from the home and their rights as a resident. EVIDENCE: Each resident is issued with a contract of terms of conditions, which outline the conditions of the home; it is signed on their admission to the home. Each person who is funded by a funding agency also gets a copy of the agreement between the home and the agency. It must be clear about the relationship of the person if any, who signs on behalf of residents. A copy of all contracts of terms and conditions should be kept on the individual personal file. The staff team have training and the experience to meet the needs of the present resident group. Alexandra Court DS0000001410.V284032.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): 9 & 11. The home’s medication procedure is not in line with the ( RPS )Royal Pharmaceutical Society guidelines for residential homes. EVIDENCE: The home’s administration of medicines is carried out by the manager or senior carers all of which have had training on the safe handling of medicine, however the procedure of ordering medication and the procedure is not in line with the Royal Pharmaceutical Society (RPS) guideline for residential homes which means that homes must receive the prescription from the GP to sign, and then send to the dispensing chemist. Although there was no concern about the record keeping of medicine in the home, good practice advice was given to the manager. The medication trolley needs to be secured to the wall when not in use, and a self medication policy and procedure for residents who independently take their own medication should be in place, so that staff have a procedure in place to follow. A risk assessment should also be carried out with a plan in place of any identified potential risk. Staff are confident that they know how to deal with the death of a resident, it was clear from conversation with residents that they had spoken to staff about Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 10 their last wishes, they felt that their rights and wishes would be respected in a caring and sensitive way. The manager had made arrangements to attend a two day course on Palliative care and dying and death after which she will arrange cascade training for the staff team. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. The approach in the home about food encourages residents to think about food, enjoy it and contribute to menu planning. Residents have well balanced meals. EVIDENCE: Residents were complimentary about the meals. The lunchtime meal, of roast chicken, swede, carrots sprouts and gravy, was nutritious in value. There was also choice of ham with white sauce; residents said if they did not like what was on offer they still had the opportunity for something other of their choice. Residents are also given a choice of food at evening meal, which includes a selection of hot and cold dishes. Mid-morning, mid-afternoon and supper snacks are also provided. Adapted cutlery and crockery is provided if this was the individual need staff said as it helped retain independence. When assistance was needed this was seen as given in a sensitive and dignified way. Alexandra Court DS0000001410.V284032.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): 16 & 18. Residents and relatives feel comfortable in raising concerns on a day-to-day basis and have access to a formal complaints procedure that is clear. Residents could be at risk if a full policy procedure and staff training on adult protection is not available. EVIDENCE: There is a complaints procedure, which is part of the statement of purpose and service user guide, and is also posted on notice boards in the home. However the procedure needs amending with a timescale when the complainant could expect a response their complaint. No staff have had any training on adult protection to recognise and report any allegations of abuse. Some however, had discussed the issue as part of their NVQ training course; the manager also had not undertaken any training on adult protection or POVA first. Information on the local contact person for adult protection was given so that arrangement could be made for training for the manager and the staff team on adult protection awareness. The adult protection policy and procedure must be clear of what is abuse and what staff must do if an incident occurred. A copy of the local multi agency procedure must also be available in the home and be readily available to staff, to provide them with the information they need, so that they understand what is meant by abuse, or recognising abuse and that there are clear procedures for them to follow. and for them to be fully aware of the term whistle blowing and who to talk to if they had concerns. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 13 It is positive to note that staff in charge of the home have contacted the CSCI area office and the local adult protection unit for advice on an incident in the home. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 25. Residents live in a pleasant, comfortable and well-maintained environment. The practice of using portable heaters is a potential risk to residents. Aids and adaptations are fitted in accordance to the needs of residents. EVIDENCE: Bedrooms were very comfortable and individualised with personal possessions creating a homely touch. Minor repairs are carried out regularly. Communal areas have been furnished to meet the needs of residents, during the course of the walk around the home it was noted that in some bedrooms and one of the sitting area portable heaters were being used. There was a carpet in one area that was identified to the manager as trip a potential hazard. Radiator guards had been fitted to most radiators, however the radiator in the dining room had no guard, this radiator was found to be hot. Bedrooms in the new extension also had no guards to radiators which were also hot to touch Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 15 these was seen as potential risk to residents in these rooms, if they fell or rested on them for a short length of time. The use of terry towels in communal bathrooms and toilets must cease, so that infection control is not compromised and that residents are not in danger of cross infection. The inspector was concerned about the spotlight lighting in one of the rooms, although it would appear to be satisfactory, it did appear to be subjectively dark. It was noted that chairs are strategically placed around the room under each spot light, However, this does not give residents a choice to move the chairs if they wished. During the course of the inspection of the home it was found to be clean and free from odour in the communal areas and bedrooms. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 16 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): 27 & 28. The staff are experienced, and are given on going training and know what they are doing. They have good relationships with the residents and care for them well. EVIDENCE: Two members of staff were spoken with during the inspection. They are well organised and there are well established systems of shift handovers, staff have access to up to date information about the residents. It was evident that staff feel comfortable in contributing to discussions. The staff spoken with knew each of the residents well and the relationships were good with a lot of warmth. Staff were observed to be professional but personable in their interaction and the residents spoken with praised the staff for their caring and supportive approach. The survey questionnaire results of the Commission showed that there is a high level of satisfaction with the care and attention given at the home. Three care staff have NVQ 2 and five care staff have started (NVQ) National Vocational Qualification Level 2 training. There was a plan for training for the year, which is reviewed regularly to make sure that all staff have the training to meet the needs of the residents. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36 & 38. The home is well managed and the interests of the residents are the main concern of the manager and staff. EVIDENCE: The manager is undertaking the Registered manager award course and has experience of the resident group, She likes things right for the residents and support staff to make sure this happens. Both resident’s visitor’s and staff said the manager is approachable and has a very open and consultative style of management. The information from CSCI survey questionnaire relatives and staff were positive with their comments about the home’s leadership. Staff have regular one to one supervision which is carried out by the home’s administrator with input from the manager with regards to issues relating to residents and their training. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 18 Risk assessments have been carried out of the building and any equipment used by staff. Health and safety noted at this inspection has been identified in standard 19 to 26. Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 19 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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 3 X X 2 2 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X X 3 X 2 Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15 Requirement Risk assessment must be carried out of any potential risks to residents and plan of action to be taken to minimise the risk must be made. Policy and procedure must be in place for the self-medication by service users. Staff must have training on dying and death. The complaint procedure must include timescale Staff must have training on adult protection awareness. The manager must make sure that the home has an adult protection procedure that is clear of what is abuse and what to do when an incident occurs. The use of portable heaters must be eradicated, as they can be a potential fire hazard. All radiators that meet the requirement of the building regulation must have a guard fitted. All communal bathrooms and wc’s must have liquid soap and paper towels. DS0000001410.V284032.R01.S.doc Timescale for action 30/05/06 2 3 4 5 6 OP9 OP11 OP16 OP30 OP18 13.2 18 22 18 13 .6 30/06/06 30/07/06 20/05/06 20/06/06 20/05/06 7 8 OP38OP25 OP38 23 13 15/05/06 20/05/06 9 OP26 13 20/05/06 Alexandra Court Version 5.1 Page 21 10 OP25 23 Some consideration should be given for the change in the light fitment in the sitting area identified so that resident can choose where to put their chair and sit. The registered provider must send an action plan to CSCI area office. The lighting in the lounge identified to the manager needs to be checked to make sure the lighting in this room comply with the building regulation requirement. Action plan from the provider is needed. The registered provider must make sure that 50 of care staff have an NVQ. The manager must have a management qualification. 20/05/06 11 OP25 23 20/05/06 12 13 OP28 OP31 18 9 30/11/06 30/11/06 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 OP2 Good Practice Recommendations There should be clear indication on the terms and condition of residency contract of the person signing on behalf of the resident. An agreement with the home should be in place for residents who self medicate. The manager should make sure that the medicine trolley is securely fixed to the wall when not in use. 2 2 OP9 OP9 Alexandra Court DS0000001410.V284032.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds 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 DS0000001410.V284032.R01.S.doc Version 5.1 Page 23 - 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. 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