Inspection on 11/02/08 for Alexandra House

This inspection was carried out on 11th February 2008.

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 House 07/04/09

Alexandra House 20/01/09

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

CARE HOMES FOR OLDER PEOPLE Alexandra House 143 High Street Pensnett Brierley Hill West Midlands DY5 4EA Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 09:00 11th and 21st February 2008 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 House DS0000070250.V353719.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 House DS0000070250.V353719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 143 High Street Pensnett Brierley Hill West Midlands DY5 4EA 0121 434 3996 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) suebastable@alexhouse1.fslife.co.uk Mr. Jayantilal James Bhikhabhai Patel Susan Bastable Care Home 50 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (30), of places Physical disability (10) Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care with nursing, and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - Old age not falling within any other category (OP 30) - Dementia over the age of 65 (DE (E) 20) - Physical Disability over the age of 50 (PD 10) The maximum number of service users to be accommodated is 50. 2. Date of last inspection First inspection Brief Description of the Service: Alexandra House is an extended and converted house, which is registered to provide nursing care for 30 older people of which up to 10 beds may accommodate people requiring terminal illness care and 20 older people with dementia. The home is divided into two units: Rose accommodates persons requiring nursing care, including palliative care and Briony which provides dementia care. The home also provides Accident and Emergency Diversion beds, Intermediate care and GP Respite beds when required. The home is situated on an easily accessible public transport route, is close to Merry Hill and Dudley shopping centres and other local shops and amenities. There is a carparking facility to the side of the building and a garden, which is mainly laid with grass and secluded areas. The home also has a memory garden. For information on fees payable it is advised that the Home Manager is contacted. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried the inspection out over two days. An Expert by Experience also visited on the second day 21st February 2008. The home/provider did not know we were coming. The manager was present during day two of the inspection. Information for the report was gathered from a number of sources: a questionnaire was completed before the inspection by the homes manager which was sent to us; on the day of the inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home, discussion with the manager and care staff plus visitors and residents. Some residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used to inform the inspection process. Five residents who live in the home were ‘case tracked’ this involves establishing people’s experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of the care that they receive. Tracking people’s care helps us understand the experience of people who use the service This is the homes first inspection since its ownership changed in August 2007 although it has been a functioning care home for many years. Four requirements and six good practice recommendations were made as a result of this inspection. The inspectors would like to thank the residents, relatives, management and staff for their hospitality throughout this inspection. The quality rating for this service is 1 star. The means the people who use this service experience adequate quality outcomes. What the service does well: Good information about the home is available, enabling people to make an informed choice that the home will be suitable for their needs. Peoples’ needs are assessed before they come to live at the home. The assessment of peoples needs, gives confidence that staff are aware of their needs and will be able to meet them. People are also encouraged to visit the home prior to them coming to live there enabling them to “test drive” the Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 6 home before they come there to live. In addition terms and conditions of residence include a trial period to enable people to decide whether they like living at the home. People who live at the home receive good standards of care and their healthcare needs are met. There are appropriate systems in place to ensure that people have the required medication that is stored safely, promoting people s health and well-being. People who live there say: “I have found the staff to be helpful and friendly” and “ The staff are well trained and they are very caring”. One relative commented: ”I’ve never yet had cause for concern” and another “They look after and care for my mother very well The Home has an experienced Manager who provides appropriate leadership. People are listened to: Complaints are appropriately responded to. The quality assurance programme includes surveys to ask residents, relatives and other stakeholders their views of the home. There is safe and through recruitment of staff that safeguards people who live at the home. Well-trained knowledgeable and friendly staff provides care at the home. People who live there say: “I have found the staff to be helpful and friendly” and “ The staff are well trained and they are very caring” and relatives said. “Alexandra House is run very professionally the staff are very caring and friendly I can’t think of anything bad to say about Alexandra House” and another relative said. It seems to be well run and friendly”. What has improved since the last inspection? What they could do better: We had very positive comments from relatives and people who live at the home about care that is provided. Care records do not always support the good care practices of the home and provide the required evidence that peoples’ needs are met. Staff need also to complete care records to confirm the care that they have given. There is a need to ensure that care planning reflects peoples’ individual needs, choices and capabilities. Bed rail risk assessments should be available for people who need bed rails and any risks should be identified to protect people from injury. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 7 There is a need to ensure that there are additional baths and showers that are suitable for the highly dependent residents that the home accommodates. Medications procedures are appropriate at the home. Improvement could be made if procedures in relation to the giving of medicines covertly are reviewed. It was very positive that when we met with the Manager on day two of the inspection she had already identified weaknesses in care planning and a need for additional bathing facilities. The Manager had identified that improvements were to be made as part of the annual development plan for 2008/2009. 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 House DS0000070250.V353719.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 House DS0000070250.V353719.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): 1-6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information about the services it provides. People who wish to live at the home have an assessment of their needs giving assurance that staff are aware of their needs and can meet them. Intermediate care is provided effectively with people benefiting from strong working relationships between Alexandra House and other Health care professionals. EVIDENCE: The home has a statement of purpose and service user guide, which has been updated to reflect the changes in ownership. Copies of the Service user guide are available in residents’ bedrooms and in the reception area of the home alongside the most recent inspection report. Terms and conditions were available for all people whose care records we looked at. We were told that the terms and conditions had been updated in Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 10 November following the change in ownership of the home. The terms and conditions we saw contained the majority of required information although the fee and any contribution by a third party such as a Social Services Department was not included. People being admitted for long term care all have an assessment of their needs before they come to live at the home, by a senior member of the homes staff. People who are admitted for intermediate care have an assessment of their needs undertaken by a member of the hospital staff which is then faxed to the home. The home will then undertake a full assessment of their needs after they have arrived at the home. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. Sadly though many people are unable to take this opportunity, as they are frequently too frail. The home has ten beds for people requiring palliative care in their last weeks/ days of their life. Staff all receive training to increase the knowledge and understanding of palliative care. The home has good relationships with Macmillan nurses who support staff to ensure that care practices are good and meet peoples needs. There is also has a twenty bedded dementia care unit at the home. We found that the majority of staff have received training in dementia care but this has slipped and more recently appointed staff have not. Care staff work between both Briony and Rose, some staff voiced concerns that not all staff were happy working on the dementia care unit. We did observe that some staff did appear more motivated than others and had a better understanding of people with dementia. We discussed with the Manager a need to explore this further. The intermediate care unit is incorporated into Rose unit. There are no separate rooms (lounge/dining room) as the Manager said that residents preferred to be altogether. Staff receive ongoing training in the care of people who require intermediate care and demonstrated good understanding of intermediate care. Physiotherapists and Occupational Therapists visit the home most days and said that they have good relationships with the home. Alexandra House DS0000070250.V353719.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): 7-11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The use of care plans that are all the same gives no assurance that individual needs, choices and capabilities are known and will be met. Medications are well managed and promote people’s health and wellbeing, although required changes to the use of covert medication will improve this. People are treated with respect and their privacy upheld. EVIDENCE: People who live at the home have a plan of their care giving staff information on how their needs should be met. All care plans we looked at were the same presuming that everyone had all the same needs, with no differences in choice, capability or need. Care plans are reviewed monthly by staff signing each element, although we were unable to determine if there were any changes needed in the persons care. One example that we were unable to identify a change of need one person was identified as needing a “high protein “ diet. We were able to determine that this resident may have needed a special diet to assist in healing a pressure sore that they had when they came to live at the Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 12 home. It is very positive that the sore has healed since they came to live at the home but nothing to suggest there was no longer a need for a high protein diet. Staff told us that this resident did not have a high protein diet. Resident care records seen did have a care plan for social activities but generally they didn’t tell us what they liked to do. One comment said: “ Encourage friends and families to join in activities and go out to their home”. Yet sadly this person’s relatives live abroad and due to the distance have been unable to visit. The Manager in her annual plan has identified as need to develop person centred care planning at the home that reflects individual’s people’s choices, needs and capabilities. People have risk assessments in place for the pressure sores, nutrition and falls, which are reviewed monthly. We did review two peoples’ care records that needed for bedrails yet no risk assessment was available. There are also risk assessments available for the moving and lifting of residents although when a problem was identified there was an insufficient management plan to address the risk. The only actions we saw for one person was: “ Needs 1-2 staff usually manual techniques”. We found it difficult to understand these instruction and lacked details about what assistance they needed into a bath and transferring to and from a bed or chair. We looked at the records showing when people had had a bath/ shower, which showed that people do not have a regular bath or shower. There were no records that one resident had had either a bath or shower although they had lived at the home for several weeks, another resident had not had a bath or shower since 19/12/07 and another since the 5/1/08 (although previous records showed that this person was having daily showers). Another resident had a record of them having a bath/shower only on the 8/2/08, 26/1/08, and 8/1/08. We did discuss that residents were not being bathed regularly with the Manager. We were also concerned that there is a lack of suitable baths/showers for dependant people. The Manager said that she knew that residents were having regular showers but felt that staff were not recording this and would ensure that it was addressed People are weighed when they come to live at the home and at least monthly. It was pleasing to see that people have put weight on since they come to live at Alexandra House showing that their nutritional needs are met. It was also positive to see that staff record triggers for challenging behaviour and describe which “de-escalation” measures should be used. It was evident that staff are aware of these instructions. We observed staff managing an incident of aggression professionally and deescalating the incident between two residents. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 13 Care records did show that residents have appropriate access to other health professionals such as Doctors, Opticians, Dentist and Speech and Language Therapists. We did find that staff had not always recorded when a Chiropodist had seen people. Relatives spoken to were very positive about the care that their relative received and said that they were kept informed of any changes in their health. One comment was: “If we have to telephone to check on any health problems she is encouraged to talk to us over the phone” and “She always gets the support she needs although at times this may be difficult”. The storage and administration of medicines at the home is undertaken by qualified nurses and is done both safely and appropriately. We did find that there is “consent to give medicines covertly” in all care files that we looked at. Covert medication means giving medicines without the person being aware that that are taking the medicine, for example put into a sandwich or put into their porridge. All assessments had been signed by the residents Doctor as acceptable and the person’s representative. The assessments recorded all the persons medication making it look as if all of the medication could be given covertly. When we spoke to staff it was evident that it was only certain people and only limited medication that they gave covertly. We discussed a need to say what medicine should be given covertly, how it should be administered covertly and why there was a need to give it covertly. The Manager agreed that she would do so. People told us that their privacy is also respected. We observed staff to knock before entering bedrooms and toilets and interact in a friendly and open way using people’s choice of name. The home has end of life care core care plans to provide staff with information about the person’s choices of “end of life” care. The Manager also plans to introduce the Liverpool care pathway so that staff can ensure that people whose Doctor does not visit regularly will have medication as they need it. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 14 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): 12-15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A range of activities are available but there is a need to more fully explore peoples interests and choices to give assurance that activities and daily life at the home meets peoples needs. Food is tasty and homemade and is enjoyed by the homes residents. Residents are able to maintain contact with their friends and families. EVIDENCE: Activities in the home are mainly organised by the care staff. There is music to movement and a craft sessions twice a week enabling residents on both units to enjoy one session a week of each. The home also has a singer who comes into entertain residents once a fortnight. A local church also has a short service at the home each month. Staff on the dementia care unit have started to identify people’s life history with the help of person or their family. A record of life history is a good way to try and ensure that activities and daily life within the home meets people’s Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 15 choices, needs and capabilities. Information gained from the life history however needs to be transferred into a their plan of care. We did see that staff had started to determine resident’s preferred daily routine such as the time they get up or go to bed. It was identified that one resident preferred to get up between 8 and 9 but their daily records consistently identified that they were “got up by night staff and were in the lounge at 7am”. There is a need to ensure that whenever possible residents wishes are respected. One person commented: “Personally I am happy how things are.” People who live at the home are able to have visitors at any reasonable time in the day. We observed several visitors arriving and leaving during the day of the inspection. Visitors we spoke to were all very positive about the home. “I have no complaints at all”. We were told that there is a four-week menu, although it was not available on day one of the inspection. A record of meals cook over recent weeks showed that there is usually one main choice with additional option of either a jacket potato or salad. It was positive to see that in an effort to ensure that residents eat a well balanced diet “fruit smoothies” are available most teatimes. Snacks are available throughout at the day and supper is always available. Service users comments about the food included: “Oh its very nice” Staff were also very positive about the food and said: “The catering is exceptional and everyone is well fed”. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to highlight concerns and are assured that they will be listened to and their concerns responded to appropriately. Staff are made aware of what is abuse and are aware of appropriate actions, which should be taken to safeguard people from abuse. EVIDENCE: The complaints procedure is displayed in the hall of the home and also included within the service user guide. There have been three complaint made about the home including one complaint that came direct to the Commission for Social Care Inspection (CSCI). We did a visit to explore the concerns highlighted, which were that one person did not have adequate pain relief. Our finding were that there should have been better liaison between staff and the family and if this had been done any concerns would have been addressed. We found that all complaints had been appropriately responded to within required timescales. Information on Advocacy service was not seen at the home during this inspection. We advised staff of a need to ensure that they were aware of their responsibilities under the Mental Capacity Act particularly as the “friend” of one Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 17 resident had signed their consent to give covert medication to a resident. We also advised that information on Advocacy services should also be available. The Home has an appropriate adult protection policies and procedures. There have been two Adult Protection Investigations in the previous six months during which the home did take all required actions. When we spoke to staff they were aware of their responsibilities to highlight poor practice and were clear of what actions they would take. Staff receives training in adult protection with evidence seen during the inspection. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean, warm and homely. There are a range of aids and adaptations available but the availability of suitable bathrooms to meet the needs of dependant people is inadequate. EVIDENCE: The home is clean, generally homely and warm. We were told that the new owners have identified an ongoing refurbishment plan. Several bedrooms upstairs were being decorated at the time of the inspection. We did find that the Dementia Care Unit lacking homeliness although staff have clear improvements identified for this unit. Improvements that staff told us about include putting people’s names and addresses on the doors. Each resident will have their a choice of decoration such as flowers or a window to help them identify it as their room. There is also a “bar” being developed in the main lounge. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 19 The home has a large lounge/ dining room on Rose and also a quiet room for visitors. Briony also has a lounge/ dining room and a small quiet lounge. There is a pleasant small garden at the back of the home. There is no safe garden area for people with dementia to wander limiting them to remain inside. The home has a variety of aids and adaptations throughout which are suitable for dependent people and a staff call system throughout the home. Toilets are situated throughout the home, are accessible and have grab rails. There is an assisted shower room on first floor of Briony and another bath but staff told us that they don’t use it as it is difficult to access it. Staff told us that they prefer to use the Parker bath on Rose unit which can be used for very dependant people. We felt that the current lack of assisted bathing facilities may have resulted in records showing that people are bathed infrequently. Rose unit has the Parker bath and an additional three showers available for the thirty people who live on this unit. We found the toilets and bathrooms to be clinical and institutional and require refurbishment. We were told that the previous owners had removed the downstairs assisted bath on Briony, this is being replaced by the new owners. All bedrooms were found to be pleasant, clean and in most cases personalised with peoples treasured possessions such as photographs, pictures and ornaments. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good mix of staff in sufficient numbers to provide consistency of care to meet peoples’ needs. The home has a skilled and knowledgeable staff group who understand and meet peoples’ needs. Recruitment and selection processes are to a good standard and protect vulnerable people. EVIDENCE: The home is staffed with appropriate numbers and skill mix to meet people’s needs. Staff we met spoke positively about support and training they receive at the home. We also found that when we spoke to staff they were knowledgeable about peoples needs. Training at the home is supported. All new staff receive formal induction training which the Manager was able to confirm meets the “Skills for Care” standards. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 21 It is very positive that the standard of 50 of care staff being trained to National Vocational Qualification (NVQ) level 2 standard has been exceeded at the home. Staff recruitment and selection is completed to the required standard. All staff files seen contained appropriate checks such as criminal records checks, references and when appropriate nurse registration. The Manager also keeps a record of the interview. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and people who live at the home benefit from this. The home regularly reviews its performance, which includes seeking the views of people who live at the home and their families. The sound financial management of the home and arrangements for safekeeping of their money safeguards people who live at Alexandra House. Staff receive supervision and direction to ensure that people receive consistent quality care. The health, safety and welfare of people is promoted and protected. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home is led by an experienced and well-qualified nurse manager and is supported by a committed staff group. We found that staff feel supported by the Manager and there is a good atmosphere amongst the staff. The manager holds frequent staff meetings and maintains a record to ensure that staff are kept updated and informed of changes. The home has a quality assurance programme. There are audits of practices within the home and surveys of peoples’ views are undertaken annually. Findings of the audits and peoples’ view inform the development plan for the home. The home does not act as appointee for service users or handle money, a procedure is in place to bill people for services such as hairdressing and chiropody. One person has their money kept under Court of Protection arrangements we advised that the home should make arrangements to ensure that they could have more timely access to their money, rather than potentially being “in debt” to the home. Staff receive supervision at regular intervals, records seen showed us that it covers all aspects of practice. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in health and safety, moving and handling and fire safety. There are records to show that the home has monthly fire drills. We saw comments such as “Fire drill went well” but there was no record of ken part in the drill. Maintenance contracts were randomly selected and were found to be up to date. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 24 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 2 3 2 3 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 1 2 2 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 2 3 2 3 Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 Care plans must identify all the persons needs and when updated must show when changes are made to their plan of care. The arrangements for bathing residents must be reviewed to ensure that people are bathed regularly and to promote their health and wellbeing. When people need bedrails they have a suitable risk assessment in place. Proposals to provide sufficient and appropriate bath/showers at the home must be forwarded to CSCI to give assurance that facilities are suitable for peoples needs. Timescale for action 30/04/08 2 OP8 12(1)(a) 30/04/08 3 4 OP8 OP21 13(4) 23(2)(j) 30/04/08 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000070250.V353719.R01.S.doc Version 5.2 Page 26 Alexandra House 1 2 3 Standard OP4 OP7 OP9 4 5 6 OP15 OP35 OP38 Staff are employed to work either on the Dementia Care unit or the Elder Frail unit. Care plans should be person centred and reflect all people’s needs, choices and capabilities. The agreement to give “Covert medication” should be reviewed and reflect the reasons why covert administration is required, how the medicine is given covertly and what medicines can and should be given covertly. There should always be an equitable choice of meal available. Arrangements should be reviewed to ensure when people are under “Court of Protection” they can access their money when needed. Records of fire drills should include the names of staff that take part in the fire drill. Alexandra House DS0000070250.V353719.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 House DS0000070250.V353719.R01.S.doc Version 5.2 Page 28 - 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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