Inspection on 11/10/07 for Alexandra House

This inspection was carried out on 11th October 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alexandra House 03/08/09

Alexandra House 30/08/08

Alexandra House 20/05/07

Alexandra House 16/06/06

Alexandra House 28/02/06

Alexandra House 02/09/05

Alexandra House 22/04/05

Alexandra House 11/02/05

Alexandra House 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Alexandra House 2 Alexandra Road Gloucester Glos GL1 3DR Lead Inspector Mr Richard Leech Key Unannounced Inspection 11.10 – 14.50, 10.00 – 18.30 11 , 12 & 14 October 2007 & 14.30 – 18.10 th th th Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 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 DS0000016360.V348155.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 Adults 18-65. 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 DS0000016360.V348155.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 2 Alexandra Road Gloucester Glos GL1 3DR 01452 418575 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) www.craegmoor.co.uk Cotswold Care Services Limited Mrs Alison Claire Avery Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2007 Brief Description of the Service: Alexandra House is a large, detached property in a residential area of Gloucester. The home has undergone a programme of substantial refurbishment and now has 10 bedrooms, some with en-suite facilities. There are three communal bathrooms, additional toilets, a large dining area and a separate lounge. Two of the bathrooms and one toilet have specialist adaptations such as overhead hoists and changing beds. One bedroom is on the ground floor. The other bedrooms are on the first floor. The home has two staircases, and a second lift has been built to improve access between floors. The home has a large back garden, which has been landscaped to make it accessible to wheelchair users. The home has a Statement of Purpose, which sets out its aims and objectives, as well as a Service Users Guide providing additional information about living in the home. These are available to current and prospective service users and to others with an interest in the home. The base fee was reported to be approximately £1300 per week although this is negotiated on an individual basis. Some additional charges are made. People living in the home expected to pay for chiropody, haircuts and toiletries, as well as for services such as aromatherapy and reflexology. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the inspection the manager completed an Annual Quality Assurance Questionnaire (AQAA). This is a self-assessment of how the service is performing and also includes plans for further improvement as well as statistical information. The inspection began on a Thursday morning, lasting until mid-afternoon. A second visit was made on the following day from late morning to early evening. The inspection concluded on a Sunday, lasting from afternoon through to early evening. The manager was present for the majority of the inspection. Most of the people living in the home were met, apart from two people who were on holiday. Verbal and written feedback was obtained from health and social care professionals and from relatives. Some of the staff team were spoken with, and some written survey forms were also completed by members of the team. What the service does well: The home is clean and pleasant, and is adapted to people’s specialist needs. Appropriate support is provided to enable the people living in the home to stay in contact with family and friends. People living in the home are offered a varied diet appropriate to their needs, although there is potential to increase the degree of individual choice offered. People’s personal and healthcare needs are met in ways which promote wellbeing, choice and dignity, although some aspects of practice could be improved. Generally satisfactory arrangements are in place for the handling of medication. There is a good framework for handling concerns and complaints, helping to ensure that people feel listened to. Arrangements are also in place which help to safeguard the people living in the home from harm and abuse. Good systems are in place for checking and improving the quality of the service, though there may be scope for broadening the sources of feedback. Health and safety is well managed in the home, promoting the wellbeing of staff and service users. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst the approach to admissions is generally sound, more attention to detail during the assessment process would help to ensure that a full and accurate picture of the person’s needs is in place. Although care plans have improved, more work is needed so that they comprehensively describe people’s needs and how they are to be met. There also needs to be more thought given to how any restrictions and limitations are documented. People’s degree of choice and control over their lives would be improved by taking forward different approaches to communication to help people to express themselves. Whilst there have been some improvements with activity provision, further work is needed so that the home provides a full range of individual activities which reflect people’s needs and interests. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 7 Staff are caring and committed, but providing more in-depth training coupled with a thorough system of staff supervision would help to improve the consistency and quality of care in the home. Increasing staffing levels would also promote more individualised care, more choice and a better quality of life for the people living in the home. Some aspects of practice around recruitment and selection need to be tightened up in order to safeguard service users as far as possible. Whilst there is evidence of improvement there are clearly some issues which continue to need addressing. Much has been achieved and it is hoped that this trend will continue. 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 DS0000016360.V348155.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An admissions framework is in place which helps to ensure that people moving into the home have their needs assessed and that admissions are appropriate, although a more thorough approach to assessment would be beneficial. EVIDENCE: Since the last inspection one person had moved into the home. Documentation related to their admission was seen. This included background information from their former home, care plans, assessments and reviews from healthcare professionals and the care manager, and information about their history and family. There was a completed assessment format. This concluded with the manager of Alexandra House ticking that the person was suitable for admission. The manager described the admissions process. This had included her making a visit to the person in their former home and speaking with staff there. The person had also made visits to Alexandra House. Staff confirmed that these visits had taken place, although no write-ups could be found of them. It is recommended that records be kept of introductory visits to the home. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 10 The assessment documentation on file had been completed by staff in the person’s former home. It is recommended that the team in Alexandra House complete its own assessment of prospective residents’ needs on the basis of available information. Some of the assessment material acquired contained inappropriate statements or contradictions (see next section). These should have been explored and the information clarified in order to obtain as accurate a picture of the person’s needs as possible. Over the course of the inspection it became clear that there were a number of aspects of the person’s needs and conditions where fuller information was required (see later sections of report). Ideally this information should have been gathered during the assessment and admissions process as part of making a fully informed decision about the appropriateness of the admission. Staff spoken with felt that the admission had been appropriate, whilst acknowledging that it was early days and they were still getting to know the person. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst care plans had shown improvement, further work is needed so that they comprehensively describe people’s needs and how they are to be met. People’s degree of choice and control over their lives would be improved by bolstering staffing levels and taking forward ‘total communication’ approaches. Systems are in place which help to manage the risks which people encounter in the home and community. EVIDENCE: Care plans for two of the people living in the home were looked at. Since the last inspection the service has introduced a new care-planning format which has sections covering areas such as healthcare, personal care, activities, family, communication and eating/drinking. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 12 The care plans for the person who had just moved into Alexandra House had been acquired from their previous home. It was acknowledged that the team was still getting to know the person, but also agreed that the home would need to generate its own care plans with the person as soon as possible. This is particularly so, since some of the statements contained in the inherited material were judgemental and negative or had already been identified as needing amendment now that the person was living in a new environment. There were also some apparent contradictions, which needed to be explored. For example, some background material noted specific mental health issues whilst a tick-box health profile indicated that the person had no diagnosed mental health needs. An assessment said that the person made drinks with support, but staff said that this did not happen due to the risk of scalding. Information submitted after the visit provided evidence of the team working with a specialist team within Craegmoor to begin generating up to date person-centred care plan’s specific to Alexandra House. Whilst care plans covered appropriate areas, detail was sometimes missing. For example, a care plan about communication stated that ‘speech is often difficult to decipher’, adding no more tangible information or guidance about a very complex area in respect of the person’s needs and conditions. Another care plan about eating and drinking did not include some information about approaches used to slow down the person’s rate of eating and therefore reduce the risk of choking. The manager acknowledged that more detail was needed in some cases, underlining that the care plans were working documents, which would evolve. The Care Homes Regulations specifically require that there be detail abut any specialist communication needs of service users and methods of communication that may be appropriate (Schedule 3 (3) (l). Other care plans viewed included information about people’s rights, choices and preferences. There was little direct evidence of service users’ involvement, although the manager said that there had been considerable involvement. It is recommended that this be made more explicit. Some documents seen made reference to consent and capacity issues, such as about consent to medication or sharing of information. However, the documentation seen did not include enough information about how capacity was assessed and, where necessary, about the best-interests process. This underlines the importance of staff having some training about the Mental Capacity Act, as recommended during the last inspection. Similarly, one person had a schedule for access to drinks. No care plan or other documentation was seen describing this. The only reference seen was in the communication book, which included phrases such as, “[service user] is aware when he is allowed drinks”. Where restrictions on choice and freedom are imposed there must be clear documentation of the rationale and resultant guidance along with Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 13 appropriate assessment and consideration of issues around capacity, consent and best interests. Staff confirmed that the person could help themselves to water in their own bedroom, and said that ‘drinks’ meant tea and coffee. Overall, whilst care plans had shown improvement there remains some way to go before they comprehensively describe people’s needs and how they are to be met. More training and guidance for the staff may help to promote their confidence in person-centred planning. One comment was made in a survey form about staff being asked to complete plans but not being confident about this. In the last report it was suggested that the home consider introducing a bound recording format so that daily records remained in sequence. Records seen continued to be on separate pieces of paper, creating large volumes of loose paperwork, which, in many cases, were out of sequence and hard to track through. People living in the home were seen to be offered choices, such as about when to get up, whether to eat in their rooms or the dining area and whether they wished to go out. One person was heard to be offered a choice about which carer assisted them. Staff described how they offered choices, such as about what people wore, how they spent their time and around food/drink. Many staff felt that people’s choices around activities were limited by the existing staffing levels (see next section). As described, care plans did note some people’s preferences and choices. However, communication care plans that were viewed were not sufficiently detailed, and there is considerable scope for the home to develop a more comprehensive approach to ‘total communication’. Further work in this area should help to promote service users’ decision-making and facilitate personcentred planning. Risk assessments were seen to be integrated with care plans. Although brief, they covered significant areas and outlined how risks would be monitored and managed. In some cases it was not entirely clear what risk/hazard was being assessed. Staff may benefit from further training about risk assessment and management. The manager felt the risk assessments were basic, and said that further work would be undertaken on them, alongside person centred planning, to provide more detail. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst there have been some improvements with activity provision, further work is needed on overcoming the barriers to providing person-centred activities which reflect individuals’ needs and interests. Appropriate support is provided to enable the people living in the home to stay in contact with family and friends. People’s rights are recognised, helping them to feel respected although may be scope to further develop practice in some areas to promote choice and empowerment. People living in the home are offered a varied diet appropriate to their needs, although there is potential to increase the degree of individual choice offered. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 15 EVIDENCE: At the time of the visits two people were on holiday abroad. The team cited what an achievement this had been, and also added that one person had restarted horse riding after a break of some time. There was not yet an activity programme/planner in place for the person who had recently moved in. It was accepted that the team is still getting to know the person and what they like to do. During the visits people were seen being supported to go out, for example for pub lunches or trips to the shops. A comment was made in a staff survey that there needed to be more staff so that activities could improve and for the clients to get more one on one time. Many of the staff spoken with felt that, whilst activity provision had improved, it was still being limited by staffing levels (usually at five care staff during the day), particularly in respect of individual activities with people. The manager agreed that this was a concern and said that staffing levels of six per shift had been approved and that recruitment was underway (see ‘staffing’ section). This increase would be a positive development. Transport was cited as another issue which could limit people’s opportunities to access the community. The home had two vehicles, one having been stolen. It was stated that approval had been given for the home to obtain a third vehicle. The manager also said that there was some difficulty recruiting people who were able to drive the vehicles. Daily records were checked for some of the people living in the home. These provided evidence of people accessing facilities in the community such as shops, as well as taking part in various activities in the home. An entry for one person on 25/09/07 stated that a service user had wanted to go out ‘but we did not have the staff’. The manager said that this was not the case, and that the person had gone out with the deputy manager for a walk. This indicates that some activities may not be being recorded. During the visits some people were observed to spend long periods of time in the lounge with the television on. Some feedback was received from a health and social care professional about the person they were involved with not having enough activities. A comment was received from a relative stating that although the team was trying to do more with their family member, there was a need for a better activities programme. They commented on lack of drivers being an issue at times. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 16 The manager reported that some of the people living in the home were still on the waiting list for hydrotherapy. Following the inspection the manager stated that these sessions would start at the end of October 2007 for two people living in the home. Care plans and daily records provided evidence that people living in the home were supported to stay in touch with family and friends. This was further confirmed by discussion with staff and relatives and by observation. One person said that they always felt welcome in the home and indicated that the team was good at staying in contact and communicating significant events to them. Staff confirmed that they knocked on people’s doors before entering. This was seen to happen during the visits. People were seen choosing where they spent time in the home, and whether to be alone or in company, although more of a focus on total communication may help people who cannot communicate verbally to make their feelings more clearly understood. People’s right to eat in their bedroom if they chose to was seen to be respected. Staff demonstrated an awareness of people’s rights such as to refuse medication, or to refuse a meal and request an alternative. During the visits people were seen having breakfast at different times, in some cases having chosen to have a lie-in. Other people were seen having hot drinks and snacks at different times, having indicated that they would like some refreshments. People’s preferred form of address was noted in their care plans. Staff reported that none of the people living in the home had a key to their room. Some documentation was seen on files referring to this. It was recommended that consideration be given to offering a key to the person who had most recently moved into the home. As noted earlier, there were some indications in inherited assessments and care plans that there may be potential to promote and maintain the person’s independent living skills. The person’s right to have certain drinks when they wished to was being restricted. As noted, clearer assessment and care planning was required around this. Overcoming the barriers noted about provision of activities should help to promote people’s right to access the community when and with whom they wish to. Four-week rolling menus were seen, providing evidence of reasonable variety and balance. There was reference to fresh vegetables being served. Records were seen of what people actually had to eat. As noted, staff confirmed that alternatives were available if people requested these. They also said that they Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 17 were aware, and alert to signs, of the preferences of people who did not communicate verbally about food likes and dislikes. The manager said that a nutritionist was working with the team to try to improve the menus, and that there were plans to further develop the choice of meals available to people. The idea of service users accompanying staff on food shopping trips had been suspended due to issues with staffing levels but there were plans to reinstate this in due course. The AQAA noted that there were also plans for service users to have more involvement with food choices and menus. Again, total communication approaches should help with this. Staff spoken with were aware of the eating and drinking guidelines of one person whose care was looked at in more detail. One person was asked about the food served in the home and indicated that they liked it. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for people’s personal care needs to be met in ways which promote choice and dignity, although some aspects of the way that personal care is recorded and delivered could be improved. Whilst the health of the people living in the home is being promoted, there is scope to improve aspects of practice, including liaison with community professionals, in order to optimise people’s wellbeing. Generally satisfactory arrangements are in place for the handling of medication, helping to ensure that people stay safe and well. EVIDENCE: Care plans provided guidance for staff about how to support people with their personal care needs. There was reference to people’s preferences and choices, although as noted this could be expanded. Staff spoken with described how they provided personal care in ways which responded to people’s needs and, as far as possible, choices. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 19 People living in the home appeared to be well cared for and appropriately dressed. Staff were seen to provide personal care support in a discreet and sensitive manner. A family member was positive about the quality of the care and indicated that their relative was offered choices about how personal was delivered. Two separate notes were seen in the communication book which suggested that scratches on a service user may have resulted from staff not adhering to the policy about not wearing jewellery when providing personal care. The manager felt that this was not the case, but it was agreed that this should be investigated. Body maps showing the extent/location of the scratches could not be found. The same person had an exercise programme devised with the help of physiotherapists. Staff understood that they were taking place on most days apart from when challenging behaviour made this impossible. Records were checked for completion of these exercises. During September 2007 they were found to take place about every other day, which accorded with guidance for minimum frequency. However, for October 2007 only 2 dates had been noted when exercises were completed (up until October 14th). Care should be taken to ensure that these do not slip. It may be beneficial to arrange for newer staff to have appropriate training about how to support the person with these exercises. During the visits one person experienced a seizure requiring an ambulance to be called. Some staff were asked about protocols around seizures. Whilst satisfactory knowledge was generally demonstrated there was some inconsistency about under what circumstances an ambulance would be called. It is very important that all staff have a clear understanding of the protocols around seizures. See also comments under training in ‘staffing’ section. The deputy manager pointed out some newly calibrated equipment allowing the weight of people using wheelchairs to be taken in the home. Weight charts were not checked during these visits. However, it will be important to ensure that people’s weight are checked regularly, including for the newer service user, in order to monitor changes. Health information in respect of the person who had most recently moved into the home was looked at. There was some background information from healthcare professionals and other workers, although it was clear that the team would need to collate and update the information. For example, there was little information about the progressive condition that the person experiences. There was uncertainty about the status of an old exercise routine developed by a physiotherapist whilst the person was living in their former home. Regarding routine checks, documents stated that the person’s vision Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 20 was normal but gave no information about eye health and vision was last checked. Updated and comprehensive healthcare information will need to include details about routine checks, healthcare conditions and associated support needs. Following the visits to the home it was reported that further work was taking place about this. Evidence was supplied of the team taking this forward in conjunction with healthcare professionals. The organisation has a health action planning format which the manager said would be implemented. There was evidence that the team was now working closely with the local Community Learning Disability Team again. There was some positive feedback from healthcare professionals about people living in the home appearing to be in good health and well cared for. However, ongoing concerns were expressed about some issues, principally: • • • Attendance at training sessions run by the Community Learning Disability Team not always being as good as expected. Difficulties with communication which sometime meant that information got lost and recommendations were not consistently followed through. Staff not having sufficient knowledge about the needs and conditions of people living in the home (see also section about training). The manager said that arrangements had been made for all service users to have a dental check up. Arrangements for handling medication were checked during an inspection in July 2007. They were found to be adequate, although one requirement and a number of recommendations were made. Medication storage appeared to be in order. A fridge was available for medication needing cold storage. Internal and external preparations were separated. However, it was noted that the temperature record for October 2006 was sometimes marked as 26°C. If accurate, this is too high. Records were sampled and also appeared to be satisfactory. Two staff are now signing for administration as a double check. However, the signature list of people authorised to administer medication was out of date and should be redrafted. It was stated that staff are only permitted to administer medication once they have received training from the supplying pharmacy and passed an in-house competency assessment. In the last inspection it was found that these competency tests were not happening regularly. The manager stated that this had been addressed and that she planned to undertake annual competency tests for all staff. Examples of medication training certificates and competency tests were seen on selected staffing files. The communication book provided Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 21 evidence that newer staff were being put forward for medication training in November 2007. Examples of protocols for medication used as required (PRN) were seen to be clear and up to date. An up to date reference guide about medication (British National Formulary) was seen. An updated medication policy dated September 2006 was also seen. The manager had introduced a system of daily checks of the medication administration record and blister pack contents. This was ticked as being completed one or two times per day. It was agreed that the record should be headed up so that it is clear what is being confirmed as checked when staff tick the chart. The organisation has a number of regular audits, some of which include checks on medication (see section about quality assurance). The manager said that there had been an audit the week before arranged through head office. The outcome was that there were no major issues, but that less stock should be held and there should be double-signed medication administration records (hence the introduction of this practice). Staff also reported that monthly systematic audits would be restarting to check records and stock levels more thoroughly. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 22 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A satisfactory framework is in place for handling concerns and complaints, helping to ensure that people feel listened to. Arrangements are in place which help to safeguard the people living in the home from harm and abuse. EVIDENCE: Copies of the complaints procedure were seen on people’s files, in the Service Users Guide and on display in various locations in the home. It was pointed out that some copies were out of date and should be replaced with the current version (notably in the office and in the file of the person who had just moved in). Text and more accessible versions were available. The AQAA noted plans to make the complaints procedure more user friendly. This would be a positive development. The manager reported that the service had a good and improving relationship with relatives of the people living in the home, and expressed confidence that they felt able to complain. CSCI is aware of complaints and concerns being expressed by family members, indicating that they feel able to raise issues. One relative who provided direct feedback said that they would feel able to Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 23 raise concerns if necessary, and expressed confidence that they would be listened to. It was reported that there were plans to reintroduce periodic meetings for family members. The record of complaints was checked. In the past recording of concerns and complaints and the ensuing investigation and outcome had been poor. A central log was now seen to be in place, including a summary of complaints and actions. Staff spoken with described how they would recognise if different people living in the home were expressing unhappiness, and talked through how they would respond. The handling of service users’ finances was checked. In the last inspection issues had been picked up resulting in some people being out of pocket. The manager said that the policy had been clarified around covering the cost of staff refreshments when accompanying a service user out. Staff spoken with confirmed that the home covered these costs and set a limit. Records showed that people had been refunded in response to the findings of the last report, although it was agreed that one other person was due a £4 refund and this was done on the day. Records of transactions and accompanying receipts were sampled. These appeared to be in order. However, it was noticed that a store loyalty card had been used on 05/04/07. The manager agreed to investigate whether this belonged to a staff member or to the service user. The home will be asked to feed back to CSCI about this. The manager said that staff had been reminded to always provide a printed receipt for all transactions unless this was impossible. The company’s internal audit department conducted a financial audit on 18/10/07 and a copy of the report was forwarded to CSCI. The home was awarded three stars (out of five) and arrangements were found to be generally satisfactory. Policies covering adult protection and whistle blowing were seen. Staff spoken with demonstrated an awareness of their responsibilities around adult protection and reporting of concerns, and expressed confidence about raising issues with management if necessary. They confirmed that they had received adult protection training. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A clean and pleasant environment adapted to people’s needs is provided, promoting their comfort and quality of life. EVIDENCE: All communal areas and bedrooms were checked. Since the last inspection new carpeting had been laid throughout the corridors, stairs and lounge. A new sofa had been purchased. There were plans for further improvements including new curtains in the lounge. Bedrooms were seen to be personalised and had fresh, individual décor. One person’s en-suite was found to have a drainage problem resulting in water flowing towards a radiator cover. The manager contacted CSCI following the visits to confirm that this had been resolved. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 25 A problem with the drainage in another person’s en-suite was reported to have been resolved. A paper towel dispenser had been installed in the room. On one of the visits there was a strong odour in parts of the home. This was discussed with the deputy manager, who explained the probable cause. It was accepted that the team was trying to address this issue but that, at times, this could present challenges. Clearly these efforts will need to persist. During the other visits the home was free of offensive odours. The sensory room was not in use at the time of the visits. The manager said that this was going to be brought back into use, and that they were hoping that work would be approved for enlarging the room to facilitate access for people who use wheelchairs. Specialist equipment was seen throughout the home. Staff reported that this was all in working order. There was evidence of the team working with professionals in the community to obtain new equipment when recommended. The main shaft lift was reported to be in good working order. The control panel was loose by the ground floor entrance. A contractor fixed this during the course of the visits. The garden was seen to be well maintained. The deputy manager said that the home had a gardener, and that there were plans to make further improvements to the grounds. It was reported that the home had a cleaner. The home was found to be generally clean throughout, although the fridge in the dining area was becoming dirty and should be cleaned. Fly screens were fitted in the kitchen. Certificates were on display evidencing that the cook had received training not just in food hygiene but also in areas such as infection control, COSHH, health and safety, fire safety and moving & handling. The laundry was checked and found to be clean and tidy. A new washing machine had been obtained and a new tumble drier was said to be on order. Records were sampled of the temperatures of fridges and freezers and of cooked meat. These were satisfactory. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are caring and committed, but providing more in depth training coupled with a thorough system of staff supervision would help to improve the consistency and quality of care in the home. Increasing staffing levels would promote more individualised care and a better quality of life for the people living in the home. Some aspects of practice around recruitment and selection need to be tightened up in order to safeguard service users as far as possible. EVIDENCE: According to the AQAA three staff (out of 14) had achieved a relevant National Vocational Qualification (NVQ) at level 2 or above, with two more people working towards this. During the inspection the manager gave an update, stating that there were now five staff (out of 16) who had achieved this and that another two people were on the programme. The AQAA noted plans to enrol more staff on the NVQ programme. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 27 Staff were seen to interact with the people living in the home in a warm, professional manner and to be attentive to their needs and wishes. One staff member was seen to move a person using a wheelchair from behind with no warning or commentary/explanation. Some conversations were also heard between staff talking about some of the service users in front of them and others in ways which could be regarded as disrespectful. Although these incidents were the exception, there is clearly still work to be done on attitudes and values, perhaps reflecting the newness of some of the staff team. Positive feedback was obtained from relatives and external professionals about the care provided by the team. People commented on the commitment of the staff, how well they understood service users’ needs and communication, and on the rapport they had with people living in the home. There was some concern about turnover of staff, accompanied by acceptance that this was normal in a care setting. Clearly the systems for induction, training, mentoring and supervision have a key role to play in ensuring that these values and skills are transmitted to newer members of the team. Staff spoken with demonstrated varying levels of knowledge about people’s needs and conditions. Healthcare professionals provided feedback about staff sometimes using terms but not understanding their clinical meaning, such as the word ‘manic’ to describe certain behaviours. During the visits staff referred to some behaviours expressed by one person as ‘OCD’ (Obsessive-compulsive disorder) with no apparent assessment to back up this statement. Great caution should be exercised around employing terms which have a specific clinical meaning as they can be misleading and may result in a person being labelled as having a condition which they are not clinically diagnosed with. See section about training. It was reported that staffing levels were generally five per shift. As noted, staff spoken with felt that this needed to increase in order to provide a better quality of individual care including more scope for one to one activities. The manager shared this view, and said that there had been agreement to increase staffing levels to a minimum of six per shift, with her and the deputy manager as supernumerary. Recruitment was said to be underway in order to achieve this goal. In the last report some staff had felt that the 13-hour shifts that they were asked to do were too long, resulting in fatigue. This shift pattern remained in place. The deputy manager said that he had asked all staff individually whether they were happy with this arrangement, and that if staff had preferred shorter shifts (but working on more days of the week) then this would be accommodated. Some staff confirmed that they were asked about this. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 28 Staffing files for three people who had started since May 2007 were checked. These provided evidence of appropriate recruitment practices being followed in general, although the following was noted: • One person’s application form provided the years when certain jobs were held but not the months. One post finished in ‘1998’, with the next starting in ‘1999’. This could therefore have represented a gap in employment history of nearly two years. Such possible gaps need to be chased up and the outcome documented. People should be asked to supply the dates to/from in terms of months rather than just years. One person had supplied the names of two professional referees. However, the references on file consisted of one of these professional referees plus a character reference from a source not named on the application form. There was no explanation found on file as to why the referee had been changed. One person’s file was still at head office. This should be transferred as soon as possible once a person starts work in the care home. An email reference had been accepted. Although the email was from an address which indicated that it was authentic, references should be in writing and signed by the referee. • • • Staff training was considered. A training matrix provided evidence that most staff were up to date with mandatory areas of training. Records indicated that there were some gaps for certain staff in areas such as food hygiene, moving & handling, fire safety and health & safety. Certificates were seen backing up the information on the training matrix, although in some cases the certificates were not found or, conversely, certificates were available but the summary had not been updated. Records and discussion with staff provided evidence of staff receiving training in areas such as adult protection, equality and diversity, infection control and the management of challenging behaviour. As noted earlier in the report, staff would benefit from a more comprehensive programme of training related to the needs and conditions of the people living in the home. This may for example include areas such as mental health, autistic spectrum conditions, tissue viability, continence and profound & multiple learning disability. Comments were also made in the report about training in person-centred care planning and risk assessment. The manager said that there had been some input for staff about autism from a member of the organisation’s clinical governance team. However, this had not been provided for all staff and there appeared to be no record of this input on people’s training files. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 29 The manager said that she was qualified to train staff about epilepsy, and that she planned to provide this training for newer members of the team. This should be done as soon as possible. Healthcare professionals in the community are providing training for the team about certain specific aspects of care for the people living in the home. Staff spoken with felt generally well supported in their day-to-day work by team leaders and the managers, but commented on the lack of formal supervision. The organisation has a format for formal supervision and appraisal entitled the ‘personal performance agreement’. The three most recent supervision records for three team members were requested. However, these could not be provided. For two people there were no available records of supervision. For another person the two most recent records located were for March and April 2007. The manager said that much support was ongoing and informal. Whilst this is accepted as being the case in all care settings, it is still essential that staff have appropriate structured formal supervision meetings at regular intervals. The manager said that there were plans for senior staff to be trained so that they could conduct supervision meeting in due course. Following the inspection the manager said that dates had been booked for all staff to have supervision meetings. Longer-serving staff spoken with felt that morale had improved since the last inspection, and that sickness levels were lower. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 30 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Stable and good management has resulted in improvements to the running of the home. This needs to be sustained in order to take the quality of care to the next level. Good systems are in place for checking and improving the quality of the service, though there may be scope for broadening the sources of feedback. Health and safety is well managed in the home, promoting the wellbeing of staff and service users. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 31 EVIDENCE: The manager is a registered nurse with a background in supporting people with learning disabilities living in the community. She stated that she had begun the Registered Manager’s Award. Staff gave positive feedback about the manager, saying that she was approachable and fair. Many reported that she regularly did hands-on work with the service users. As noted in the report, whilst there remains considerable work to do to improve aspects of the running of the home, there was evidence of significant improvement in a number of areas. Just prior to the inspection the manager became registered with CSCI. The organisation has a number of quality audits covering areas such as finances, medication, health & safety, infection control and facilities. Some of these are done in-house, with others being conducted by people from different parts of the organisation. There is also a wider-ranging overview audit. Examples were seen of the various audits and of resulting action plans. These provided evidence of a good system for checking and improving the quality of the service. A report from the organisation’s clinical governance department also provided evidence of assistance being provided to the home in respect of individual care planning. The manager said that service users’ feedback is obtained on a day-to-day basis, and through involvement in person-centred care plans. More globally, the organisation also has a ‘Your Voice’ forum which provides opportunities for service users to feedback about their care. The manager said that there is no formal system for obtaining feedback from other stakeholders such as relatives and professionals. Although regular informal feedback is obtained, the team could consider ways of surveying these stakeholders in a more systematic and structured way as part of the quality assurance strategy. It was reported that periodic meetings for family members may be reintroduced. Policies and procedures were seen to be reviewed regularly. Reports of the conduct of the home made under Regulation 26 are being forwarded to CSCI. Staff spoken with felt that health and safety was well managed in the home. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 32 A health and safety file was seen containing policies and procedures which covered relevant areas. A maintenance file was viewed, providing evidence of prompt reporting and action in response to identified maintenance issues. There were also written records of checks being carried out around the home at different intervals in respect of health and safety. Documentary evidence was seen of gas appliances being checked in August 2007 and of the lift being serviced in October 2007. Certificates were seen for checks on equipment in the home in July 2007. Portable appliances had been tested in October 2007. Records for fire safety were looked at. A fire risk assessment had been carried out in April 2007. Routine checks were documented as taking place at appropriate intervals. The last fire drill was recorded as 20/06/07. Another should take place in the near future, particularly in view of there being a new resident. Some staff referred to leaving people in their rooms under certain circumstances when there was a fire. This practice should be checked with the local fire authority as the guidance may have changed around this. The fire door to the kitchen did not close properly. This was reported to have been repaired shortly after the final visit to the home. Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 33 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 3 x 3 x x 3 x Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 13 (5). 15 (1) 17 (1) a. Sch. 3 (3) (l) Requirement Timescale for action 31/12/07 2 YA7 17 (1) a. Sch. 3 (3) (q) 3 YA12 16 (2) m &n 4 YA34 19. Sch. 2 (6) Care plans must clearly state how each service user’s assessed needs are to be met (including personal care requirements, management of finances, communication, moving & handling, physical & mental health, use of equipment and management of challenging behaviour). Previous timescales of 30/06/05, 31/01/06, 31/05/06 and 30/09/06 not met. Some progress made by timescale of 30/09/07. Where restrictions on choice and 31/12/07 freedom are imposed there must be clear documentation of the rationale and resultant guidance along with appropriate assessment and consideration of issues around capacity, consent and best interests. Provide an appropriate 31/12/07 programme of activities in consultation with service users. Timescale of 31/10/06 not met. Some progress made by timescale of 30/09/07. Ensure that there is a full 31/10/07 employment history for all DS0000016360.V348155.R01.S.doc Version 5.2 Alexandra House Page 35 people working in the home. 5 YA36 18 (2) a All staff must be appropriately supervised. Timescale of 31/07/07 not met. 31/12/07 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 Refer to Standard YA2 Good Practice Recommendations It is recommended that records be kept of introductory visits to the home by prospective service users. It is also recommended that the team in Alexandra House complete its own assessment/summary of prospective residents’ needs on the basis of available information to ensure that the overall assessment is as up to date and comprehensive as possible. Update the assessment, basic information and care plans as soon as possible for the person who had most recently into the home, to make them specific to Alexandra House. Add more detail to care plans such that they more clearly describe how people’s assessed needs are to be met. Clarify whether the person who had most recently moved into the home has any mental health needs, as outlined in the text and discussed during inspection. Make it more clear how service users have been involved in their care plans, for example by recording key points from discussions or observations as relevant to different aspects of care planning. Revise documentation in care planning files dealing with issues around capacity and consent so that it is compatible with the principles of the Mental Capacity Act. Staff should have input about the Mental Capacity Act as soon as possible. Provide more training and guidance for staff around the principles and implementation of person centred planning. Consider introducing a bound recording format so that daily records remain in sequence. DS0000016360.V348155.R01.S.doc Version 5.2 Page 36 2 YA6 3 4 YA6 YA6 5 YA6 6 7 YA6 YA6 Alexandra House 8 YA7 9 YA9 Take forward plans to introduce more of a ‘total communication’ approach in conjunction with professionals in the community. Use these strategies to promote decision-making and empowerment of service users. Provide further input/training for staff about principles and practice of risk assessment and management. Continue to develop risk assessments such that they are fully clear and provide sufficient detail about the management of risks. Ensure that daily entries provide a sufficiently detailed account of people’s activities/how they spent their time. Continue to work towards providing people with more choice about what they eat/menus in general, particularly people with greater communication difficulties. Investigate the suggestion that scratches on one person may have been caused by staff not following the policy about the wearing of watches/jewellery when delivering personal care. Ensure that body maps are completed when appropriate (see examples in text). Ensure that the frequency of one person’s exercise programme does not slip, as noted in text. It may be beneficial to arrange for newer staff to have appropriate training about how to support the person with these exercises. Ensure that all staff have a clear understanding of the protocols around seizures. Further develop care plans about personal care so that they more clearly reflect service users’ preferences around how and when it is delivered and about the gender of the person providing support. Act upon comments from Community Learning Disability Team. Collate and update healthcare information about the person who had most recently moved into the home as soon as possible in order that all staff have a good knowledge of their health conditions and support needs. The signature list of people authorised to administer medication should be redrafted so that it is up to date. The record of the daily medication check should be headed up so that it is clear what is being confirmed as done when staff tick the chart. Ensure that the temperature at which medication is stored does not exceed 25°C. If it is does then measures should be taken to reduce this temperature to appropriate levels. Check whether a shop loyalty card used on 05/04/07 DS0000016360.V348155.R01.S.doc Version 5.2 Page 37 10 11 12 YA12 YA17 YA18 13 YA18 14 15 YA18 YA18 16 17 YA19 YA19 18 19 20 21 YA20 YA20 YA20 YA23 Alexandra House 22 23 YA24 YA32 belonged to the service user or a staff member, as discussed. Take appropriate action if the latter. Clean out the fridge in the dining room. When staff are providing/about to provide some kind of support for a person they should always explain what they are doing or are about to do and why. Note comments in text about attitudes and values, and also about use of terminology which has a specific clinical meaning. Take forward plans for staffing levels to be a minimum of six per shift. ‘To/from’ dates for periods of employment stated on application forms should be in months rather than just years. Where there is a change of referee clearly document the reason for this in the staffing file. Transfer staffing files promptly from head office to the care home once a person starts work. Avoid accepting email references. Check whether the information on training records is fully up to date and accurate. Ensure that any gaps in mandatory training are addressed. Provide appropriate specialist training for staff related to the needs and conditions of people living in the home, as outlined in the text. Staff who have not yet had training about epilepsy should have this as soon as possible. Consider ways of surveying different stakeholders such as relatives and health and social care professionals in a more systematic and structured way as part of the quality assurance strategy. Carry out another fire drill. Ensure that these are done regularly. If it is procedure to, under certain circumstances, leave people in their rooms behind fire doors in the event of a fire, check this practice with the local fire authority to ensure that it is still regarded as appropriate. 24 25 26 27 28 29 YA33 YA34 YA34 YA34 YA34 YA35 30 YA39 31 YA42 Alexandra House DS0000016360.V348155.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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