Inspection on 19/06/07 for Alexandra House

This inspection was carried out on 19th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexandra House 17/06/08

Alexandra House 28/07/06

Alexandra House 15/11/05

Alexandra House 08/06/05

Alexandra House 06/01/05

Alexandra House 09/08/04

Alexandra House 10/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Alexandra House Masons Court Hillborough Road Solihull West Midlands B27 6PF Lead Inspector Kath Strong Key Unannounced Inspection 19th June 2007 09:20 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 DS0000004516.V340618.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 DS0000004516.V340618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address Masons Court Hillborough Road Solihull West Midlands B27 6PF 0121 245 1081 0121 707 1090 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.sjmt.org.uk Sir Josiah Mason`s Trust Mrs Hilary Lloyd Care Home 36 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (36) of places Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28/07/06 Brief Description of the Service: Alexandra House is a registered care home for older people. The home is located on the outskirts of Solihull and Birmingham, in a residential area, close to local amenities and a bus service, which provides access to surrounding areas. The home is a single storey building, registered for thirty-six beds; all rooms are for single occupancy. The home has two lounges; two areas for dining and a conservatory, there are four assisted bathrooms and one walk in shower room available plus toilets within close proximity to communal areas, these meet the needs of residents living at the home. There is level access for wheelchair users to the front entrance and throughout the home. Corridors are wide and spacious and allow residents to move around the home freely and safely. The home has hoisting equipment available for residents who have decreased mobility. An accessible well maintained garden area with a pond is provided. The home is approached through security gates where there is ample parking for visitors, alternatively there is ample off road parking. The organisations head office is on site, the complex also provides sheltered housing and domiciliary care from separate facilities. Copies of the previous reports written for the home are available from the manager upon request, and there is a notice to advise visitors of this on the notice board. Inside the home, the reception area has notice boards, which display information about forthcoming events and other articles that may be of interest. The current charge for living at the home is £344 per week. Additional charges include chiropody, hairdressing, newspapers ordered specifically by people and personal phone rental. The home does supply two newspapers each day for people to access at their leisure. Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was undertaken by one inspector over a period of one day and was assisted throughout by the manager. The home was fully occupied on the day of the visit, two of which were in hospital. Information was gathered from speaking with people who live at the home, a relative and staff including two staff interviews. Care, health and safety and the arrangements for medications were reviewed. Some staff files were checked, this included the training they had received. Staff were observed whilst carryout out their duties. A partial tour of the premises was carried out. Prior to the inspection the manager had completed and forwarded an annual quality assurance assessment. This as well as questionnaires received from people who live at the home provided information about the services provided. These were taken into consideration as part of the inspection process. At the conclusion of the inspection verbal feedback was given the manager. It was pleasing to note that virtually all of the requirements made from the previous inspection had been addressed. No Immediate Requirements were made. What the service does well: The home provides prospective residents with a range of information and an opportunity to visit the home to talk with others and sample the food to assist them in making a decision about living at the home. People who live at the home enjoy a varied, balanced and nutritious diet and are offered choices. This was evidenced from comments made by people after they had eaten lunch, “I enjoy my food, food is very good”. Staff provide a good standard of personal care and ensure that any identified health needs are met. People spoke about their satisfaction, “It’s a lovely place to live, staff are good, they rally round to get things done because some of us take a while to get sorted”. The home has 100 care staff that have successfully completed NVQ level 2, two staff have level 3 and eight staff are undertaking the course other staff have also expressed a wish to complete level 4 training. The indicates a well motivated and skilled workforce are working for the benefit of people who live at the home. Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The responsible individual needs to address the outstanding requirement in respect of conducting unannounced monthly visits and supplying a written report to the manager. The failure to carry out this task is holding up progress regarding quality and the effect for residents. The activities provided need to be reviewed and increased to meet peoples needs and aspirations that stimulates and improves the quality of their lives. Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 7 Consideration needs to be given to allocation of a storage area for the large number of wheelchairs that people currently require for mobilising. 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 DS0000004516.V340618.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 DS0000004516.V340618.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, 2, 3, 4, 5 and 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and their representatives with relevant information about the home to enable them to make an informed decision about the homes suitability. The home carries out a pre-admission assessment and gathers other information to assess its ability to meet the respective persons needs. EVIDENCE: The statement of purpose and service user guide remain the same in content as they were at the previous inspection of July 2006. They contain relevant information about the home and the services provided to assist people in making decisions about the home. A copy of the service user guide is available in each bedroom and will be replaced if a relative wishes to take a copy out with them. The manager advised that an external consultant who has been asked to implement a quality assurance system was reviewing both Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 10 documents. The home is also planning to present the documents in cassette format for the benefit of people who have sensory impairment to enable them to have the required information in a suitable format. All persons residing at the home are given a contract of terms and conditions of residency. The document provides people with information about their rights whilst living at the home. Letters concerning annual fee rate increases are supplied to each individual. The home offers new admissions a trial period of four weeks for people to experience living at the home before a permanent placement is confirmed. The home uses a pre-admission tool to assess prospective residents needs at a venue that is convenient to the prospective resident prior to admission. This was evidenced during the course of the inspection when the manager made arrangements to carry out an assessment. The contents of two pre-admission assessments were reviewed and found to include all relevant information and whether any specialist equipment will be needed. This ensures that all of the identified needs can be met by the home on the day of admission. The manager carries out the assessments and she is usually accompanied by a team leader from the home. A relative was spoken with whose older relative had recently been admitted to the home. She advised that the family were shown round the home and the prospective resident had sampled a meal. She also said, “We were given enough information about the home before admission”. The home does not provide intermediate care. Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples health needs were being well met and in the main this was reflected in the care plans. Staff practices regarding documentation of medications needs to be more robust in ensuring that medications have been taken by the resident. Peoples dignity and respect were being well maintained by staff. EVIDENCE: Each person has a written care plan. This is individualised and describes what a person is able to do independently and what assistance staff need to supply to promote peoples health and wellbeing. Four care plans were reviewed and case tracked including the two latest admissions and others with varying needs. Files were indexed for ease of access to relevant information. Some care plans had more than one identified need. To give staff an overview of needs they included a summary as well as individual detailed care plans. The home also completes a background and social history of each person. They were found to be very informative; this Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 12 assists staff when planning the persons care and it identifies the persons’ social interests, which can be incorporated into the activities programme. Care plans appeared to cover all aspects of daily living and what staff need to do to promote peoples health. Peoples’ preferences were included such as method of bathing and times of retiring and rising. There was ample evidence of the involvement of external professions and the advice given for staff to follow. People are assisted in attending hospital appointments and tests that are needed. The home carries out assessments of moving and handling needs, skin condition and potential of developing pressure ulcers, nutrition and risk assessments. When it is identified that a person is loosing weight the home requests an assessment by the GP and a dietician in an effort to reverse the trend. These are reviewed each month by the key worker and when formal reviews of the whole care plan take place the respective individual and their representative are invited to participate and agree the care plan. Some care plans did not include a photograph of the resident to enable staff to safely identify the person prior to delivering care or medications. This is required for those staff who work infrequently in the home such as bank staff and new recruits. The manager stated that a digital camera was to be purchased soon to address the shortfall. It was noted that some people are prone to chest or urinary tract infections. It would be beneficial for short term care plans to be developed to advise staff to be diligent and how to observe for signs of recurrence of an infection. This will also assist the home in monitoring of peoples trends in respect of short term illnesses and to take appropriate action when short term illnesses occur. Some people who live at the home made comments. “I have no complaints about the place”. “Staff are good, they rally round to get things done because some of us take a while to get sorted”. “I’m well looked after”. A relative made the following comment. “Very pleased, very impressed, staff are very nice and they are there when you need she needs care”. The arrangements for medications were assessed and during the afternoon administrations were observed. All aspects appeared to be safe with one exception. The controlled drugs book was signed by both staff before the medication was taken to and offered to the relevant person. This practice fails to ensure that the medication has been consumed by the resident before it is recorded in the controlled drugs book. This was brought to the manager attention; she agreed to address the problem promptly. People living at the home were well presented and appropriately dressed. Staff were observed using the preferred term of address towards people. Personal care was delivered in the privacy of the persons own bedroom or a Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 13 bathroom. Staff were observed assisting people to another bathroom when a toilet was already occupied. Alexandra House DS0000004516.V340618.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, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to exercise choices over their daily lives. The activities programme is not sufficient to adequately stimulate people to improve the quality of their lifestyles. People receive a varied and nutritious diet, which meets specific dietary needs. EVIDENCE: Since the last inspection the home has appointed an activities organiser who has been allocated 20 hours per week to provide recreations for people who live at the home. The activities organiser was spoken with during the visit, she said that she dedicates approximately 10 hours per week to providing activities. This is due to her being new to the role and her gradual involvement. She confirmed that people who prefer to stay in their own room for the majority of the day are not included in her schedule. Questionnaires returned to CSCI from people living at the home indicated that there are usually sufficient activities, the box concerning always had not been ticked by anyone. During the visit a person living at the home said, “I would like more activities”. There is a weekly programme of activities on display, which is reviewed and re-written every week. For the current week seven mornings Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 15 and five afternoons offered various activities. The home holds regular coffee mornings and the local school is planning to make cakes and serve them to people at the home. Staff carry out regular sessions to manicure and paint peoples nails. The manager advised that she is trying to enlist the services of the local school choir to sing in the home. Special events and birthdays are celebrated with parties. A religious service is provided every month. None of the current occupants of the home have requested to be taken out to church services. The hairdresser provides two afternoon sessions per week. External entertainers visit the home, weekly motivation and movement and monthly guitar and singers provide entertainment. Alcoholic beverages are served two to three times a week when people are relaxing and socialising. There are two other buildings within the complex that offer recreations such as scrabble and bingo, which some people go to. This encourages independence and the opportunity for people to mix and socialise with others outside of their home. Families and visitors take people out to visit garden centres, meals out or to just spend time at the individuals’ own home. Extra staff are rostered to work every Tuesday to take people out who do not have relatives to provide this service. The complex also has its own minibus, which is used for outings such as a trip around Birmingham for people to see the changes and to see Walsall lights during October. The recordings made about people who attended an activity require review. Currently the activities organise makes a list of people who have participated, the manager maintains a tick list and carers record the activities in the daily records of the care plans. The home should develop a system where only one recording is made that includes whether individuals have enjoyed the activity and details of those who do not participate and why. This can be used as a monitoring tool when reviewing the activities programme to ensure that peoples’ personal preferences have been incorporated. The activities organiser needs to ensure that she fulfils her allocated hours and that people who choose not to leave their rooms are considered. This will ensure that peoples lifestyles are enriched. The home has a policy of open visiting and relatives may join residents for a meal at an additional cost. A person who live at the home stated, “I can go to my bedroom to have a nap at any time”. A relative said, “I can visit anytime, I come twice a week and other relatives visit in between”. Family members arrived to take their relative out and staff were observed providing support. A residents meeting had been planned for the following week and the external consultant who is developing a quality assurance system will chair this. Future meetings will, be chaired by a senior member of staff form the home. The manager was observed negotiating with people about which television channel they preferred. A copy of the four weekly menus was given to the inspector. People can request poached or boiled eggs each morning with breakfast. The main meal Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 16 of the day is served at lunchtime; this offers choices for the main course and sweet or yoghurts. The evening meals includes soup, light meals, cold foods and cakes for people to choose from. Snacks are offered at suppertime such as biscuits, toast, scotch pancakes and crumpets. Special diets are catered for and the menu appeared to be culturally appropriate for the current client group. Lunch was observed being served and staff were assisting people in a respectful manner. People who did not eat very much were gently encouraged to have more to ensure an adequate dietary intake is maintained. The meals served looked appealing and nutritious. Some people made comments about the meals. “I enjoy my food”. “Food is very good”. Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 17 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. The complaints procedure is accessible and gives clear instructions for people to follow if they wish to make a complaint. The home has systems in place to protect people from the risks of abuse. EVIDENCE: There is a comprehensive complaints procedure, which was on display in the lounge and a copy is included in the service user guide in each bedroom. The home maintains a file that contains grumbles and action taken and a file for formal complaints. No formal complaints have been made to the home since the last inspection of July 2006. CSCI have received one complaint making a number of allegations about the manager. The responsible individual investigated this; he was unable to find any evidence to support the allegations. This indicates that people who live at the home are able to make a complaint and are confident that it will be dealt with effectively. The home has an adult protection written policy and a whistle blowing procedure to encourage staff to report any concerns in respect of abuse. The home has acted appropriately and effectively dealt with an issue regarding a member of staff who no longer works for the organisation. Staff spoken with were able to demonstrate that they would respond appropriately if abuse is suspected. Staff have also received training in this aspect of care to ensure they have clear responsibilities concerning abuse. Alexandra House DS0000004516.V340618.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, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Alexandra House provides a homely, safe and comfortable environment in which people feel relaxed and secure. EVIDENCE: The home was purpose built and has two lounges and two dining areas for people to choose from. There is also comfortable seating at the reception area, a further small open area and in the conservatory. The second lounge is exceptionally attractive and includes tea making facilities for visitor to access. The room can also be booked for use by visitors to hold private meetings or special events with their relative who lives at the home. The room is not generally used by people who live at the home. All of the communal rooms are decorated to a high standard. The organisation employs a number of maintenance operatives and the manager of those staff was introduced to the Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 19 inspector. He reported that the home takes priority over the other buildings within the complex when repairs are needed. The conservatory leads on to the rear garden and is accessed by a ramp with handrails to assist those who have restricted mobility. The garden is pleasant well laid out and maintained. It offers further seating and a pleasing environment for people to enjoy. This fish pond is secure, the railings and netting ensures that accidents will not occur. Corridors are wide are fitted with handrails to permit good access for wheelchair users. There are a range of assisted bathing facilities including baths and showers strategically located; these ensure that people can make choices about the method of bathing. Communal toilets have raised seat The home has a large number of wheelchairs but no dedicated area for their storage. It is recommended that consideration be given to this problem. Bedrooms seen were very personalised including items of personal possessions and furniture. The occupant of one room had taken her own bed into the home. All bedrooms are supplied with a telephone point; a wall mounted television, a lockable facility and suited door locks. This ensures that people can safely store personal and financial items and respects their choices about privacy. A person who resides at the home made a comment, “I have lived here for a long time and like my bedroom”. A relative spoken with said, “Very pleased and impressed, its clean and tidy. Its one of the nicest homes I’ve seen”. The home was clean and odour free on the day of the fieldwork visit, this ensures that a comfortable and homely environment is provided for people who live at the home. A hygienic and effective system for laundering of personal clothing and bed linen was in place. The laundry room provides a service for the other buildings within the complex. Alexandra House DS0000004516.V340618.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, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are rostered in sufficient numbers to enable them to meet the needs of people who live at the home. Staff receive adequate training to provide them with the knowledge and skills to carry out their roles effectively EVIDENCE: Review of the staffing rota suggested that acceptable staffing levels are maintained to meet people’s needs. Each Tuesday extra staff are roistered to take people out to do their personal shopping or to visit a place of the persons choice. There is a full compliment of ancillary staff to permit care staff to concentrate on their roles of delivering personal care and ensuring that health needs are being met. Permanent staff cover absences such as sickness and there are a number of banks staff that the home can draw on to fill gaps. Agency staff are used infrequently and none recently. This ensures that people receive continuity of care. The home also enjoys a low staff turnover; the last two departures were for purposes of retirement. Comments received from people living at the home included, “Staff are good, staff are very nice, I get on well with the staff”. A relative also said, “Staff are very nice”. All care staff have successfully completed NVQ level 2 training, two have level 3 and a further eight are currently undertaking the course and some have Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 21 expressed a wish to carry on to level 4 training. This is impressive and ensures that the home has a skilled workforce. Four staff files were seen and these indicated that good recruitments practices are carried out. The home obtains relevant checks and two satisfactory written references before a post is confirmed. This ensures that people who live at the home are not put at risk of harm. New recruits are expected to undertake an induction programme that includes all aspects of the topics in the Skills for Care programme to ensure that they have a comprehensive introduction to their roles. There was evidence that staff have received all mandatory training and refresher courses in Health and Safety, Abuse, Fire Safety, Moving and Handling, Infection Control and Food Hygiene. Other training is provided to provide staff with the knowledge and skills to meet people’s specialist needs. They include Parkinson’s Disease, Diabetes, Nutrition, Resuscitation, Drugs Handling, Loss and Bereavement and the Mental Capacity Act. New staff are promptly enrolled to undertake course to ensure they are able to perform their roles competently. Alexandra House DS0000004516.V340618.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, 32, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the skills to oversee the home and to continue with the quality assurance programme when it is fully implemented. Arrangements in respect of health and safety are robust and prevents people who live at the home from the risk of injuries. EVIDENCE: The manager possesses a wealth of experiences and is skilled in managing the home. She was observed giving appropriate guidance and support to both residents and staff. Staff provided positive feedback about the way the home is managed. A relative who was visiting said, “She is very nice and informative”. Three team leaders provide her with support. The manager Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 23 currently carries out the majority of the on call system, she is advised to give consideration to developing a proportionate system. An external consultant was in the process of introducing a quality assurance system, he is scheduled to complete the programme by the end of July. This will suggest that the home will be able to confirm that it is striving to make ongoing improvements for the benefit of the people who live there. As with the previous inspection the responsible individual has not been completing monthly unannounced visits and supplying the manager with written reports of his findings. The manager advised that she has made numerous requests for reports to be supplied but only one was found for this year so far. This is not satisfactory and requires addressing to provide the manager with clear information about how the home is being run. The arrangements for the safekeeping and transactions of peoples personal are robust; the system prevents financial abuse from occurring. The accident records are good and the storage system permits easy access when required. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting are regularly tested and the outcomes recorded. Hot water outlets that people who live in the home have access are tested regularly to ensure that they are protected from the risk of scalds. Regular fire drills are carried out and the names of the staff who have responded are recorded to ensure that all staff are captured over a twelve month period. The arrangements appear to protect peoples who live at the home and others from risk of injury. Alexandra House DS0000004516.V340618.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 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1)(2) Requirement Short term care plans must be written in respect of recurrent illnesses such as chest and urinary tract infections. This will ensure that all needs are being met and give staff guidance on the monitoring that is required to ensure that prompt action is taken as required. Identity photographs must be available for all residents. This ensures that the correct person receives personal and health care and that medications are administered correctly. Timescale of 25/09/06 has not been met. 3. OP9 13(2) Staff must ensure that medications are administered safely by ensuring that the medication has been administered by the respective person before the controlled drugs book is signed to confirm this. 15/09/07 Timescale for action 31/07/07 2. OP7 17(1)(a) (2) Sch3 31/07/07 Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 26 4. OP12 16(2)(n) Time for activities and activities offered must be reviewed to ensure that residents are stimulated. People should be offered a range of recreational activities in line with their needs and expressed preferences to enrich their lifestyles. Records must be retained that include those who have participated and if they enjoyed it and those who refuse to participate and why. This is needed for the home to demonstrate that the activities provided are tailored to meet peoples’ preferences and aspirations. Regulation 26 visit reports must be written and available for review. Time scale of 29/09/06 has not been met. 31/08/07 5. OP33 26 31/07/07 6. OP33 24 Completion of the implementation of a formal quality assurance system for the home to demonstrate that it is continually striving to make improvements for the benefit of people who live at the home. Previous timescales of 06/06/05, 08/11/05 & 03/03/06 & 30/11/06 not met. 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 27 No. 1. Refer to Standard OP1 Good Practice Recommendations It is recommended that the service user guide and statement of purpose are available in other formats. The manager advised that this is in progress. It is recommended arm circumferences are recorded for residents who refuses to be weighed. It is recommended that a dedicated storage area be identified for storage of the many wheelchairs that are used in the home. An on call and proportionate rota is recommended to be introduced and staff clearly advised of the arrangements. 2. 3. OP8 OP22 4. OP31 Alexandra House DS0000004516.V340618.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000004516.V340618.R01.S.doc Version 5.2 Page 29 - 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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