Inspection on 02/09/05 for Alexandra House

This inspection was carried out on 2nd September 2005.

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 24 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 11/10/07

Alexandra House 20/05/07

Alexandra House 16/06/06

Alexandra House 28/02/06

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 Ms Tanya Harding Unannounced Inspection 08:00 2 September and 2nd October 2005 nd Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 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.V256800.R02.S.doc Version 5.0 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.V256800.R02.S.doc Version 5.0 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) Cotswold Care Services Limited To be appointed Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Alexandra House is a large detached Victorian house located in a residential area of Gloucester. The home has 12 bedrooms as well as a shower room, two bathrooms and a sensory room. One bedroom is on the ground floor with other bedrooms and bathrooms being on the first floor. All of the bedrooms have hand-wash basins. On the ground floor there is a spacious lounge, a large dining area, an activities room, a physio therapy room, kitchen, laundry and a small office. The home has two large staircases and a lift from the ground to first floor. The home has a large back garden. Alexandra House is one of three homes and a day centre in Gloucester owned by Craegmoor Healthcare Ltd. Significant changes are taking place to the enviornment of the home, which will result in provision of fewer bedrooms, more en-suite facilities, adapted bathrooms and toilets and a larger lift. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report provides an account of two separate unannounced visits to the home. The first visit took place on Friday 2nd September 2005 at 8.00 am lasting three hours with the main focus on assessing the home’s recruitment procedures. This visit was supported by the acting manager. The second visit took place on Sunday 2nd October 2005 at 14.30 lasting almost five hours. A number of records were checked during this visit and several staff interviewed. Both visits were supported by second inspector, Richard Leech. The inspectors were able to talk to two sets of relatives who were visiting the home. Most of the service users were met and greeted. Those not seen were out on activities or visiting relatives. Many changes have taken place in the home in the past few months and there is ongoing monitoring of the progress by the Commission and involving placing authorities. A large number of requirements from the last two inspections in the home have been addressed or partially addressed. This report should be read together with the previous inspection report from April/ May 2005 for a more comprehensive overview of the home. Since the last inspection two meetings have been held with Craegmoor Healthcare as registered providers (16th June 2005 and 10th October 2005) to assess the progress being made by the home in order to meet the National Minimum Standards and Care Homes Regulations 2001. Also included in this report are the findings of the pharmacist visit to the home on 28th June 2005. The reason for this visit was to follow up the previous specialist inspections on 8th February 2005 and 5th May 2005 by a pharmacist of the arrangements for handling medicines (Standard 20 of The National Minimum Standards Care Homes for Adults {18-65}). The inspection examined stocks and storage of medicines, Medication Administration Record (MAR) charts, other medication records, policies and procedures. There was a full discussion with the acting manager and two other staff members were spoken to. The complete feedback from this visit has been sent to the Registered Provider. The requirements made are included in this report although an action plan to address these has already been provided by Craegmoor Healthcare. What the service does well: The home has a dedicated manager who is consistently making efforts to build and develop an effective and competent staff team who can offer the right kind of support to the service users. The home was clean and odour free during both visits. Several of the service users were seen and appeared well. Two service users said they were contented and one confirmed that they were planning to access a college course in the near future and were being supported in this by the home. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home needs to develop care plans and risk assessments further and implement the necessary support for service users in line with the care plans Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 7 to ensure that what is required for people’s wellbeing is actually being done and done well. Some of the staff practices observed by inspectors were not in line with written care plans and seemed unnecessary. Staff need to be clear that their actions are in the best interest of the service users and review their approach if necessary. More work is necessary to ensure staff follow agreed plans of care and support people in line with their wishes. Communication links with parents and families are better, but could be further improved to alleviate anxieties over changes and care needs where appropriate. Recruitment procedures are still not being followed correctly in some cases and this could potentially compromise the welfare of the service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 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.V256800.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Lack of clarity around service users’ terms and conditions and how people’s finances are being managed could potentially result in infringement of people’s rights and create confusion. EVIDENCE: One person has moved from the home since the last inspection. This was a planned move in recognition that the needs of the service user could no longer be met. No new placements are anticipated at the home until the environment and the care practices are up to the required standards. This is in line with the voluntary agreement by Craegmoor Healthcare. The requirement made in the previous report under standard 3 about provision of specialist staff training in communication is commented on under standard 35. Terms and conditions for service users which the home was required to provide were not seen on main service users’ files. The Commission has been previously advised that service users at Alexandra House are not expected to make regular contributions to the home’s transport and that any change to this arrangement will be discussed before being implemented. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 10 In the last report the Commission requested information on whether service users had accumulated savings in a centrally held account from their Disability Living Allowance payments. This information has not been provided to date and the requirement is repeated. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Care plans and risk assessments provide guidance for staff on service users’ support needs, but require further improvement to ensure consistent and empowering approach is employed. Some practices in the home do not reflect the support guidance provided and this is potentially detrimental to service users who need to be supported in a consistent and safe way. Quality of care provided is being compromised by staff who are not clear about their roles and responsibilities with respect of meeting the needs of service users. EVIDENCE: The requirement from the last inspection to review and update care plans has been adhered to. However, part of the requirement which asked for care plans to include information on how people should be supported with their personal care needs and in case of behaviour challenges has not been addressed to a satisfactory level. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 12 Staff who are required to write, monitor and update care plans may not have the necessary skills and training to do this task to the necessary standard. This must be addressed. Following the last inspection, Gloucestershire Social Services have carried out comprehensive reviews of needs for each individual. Following these reviews the home has been provided with a detailed list of assessed needs for each individual living at Alexandra House. As part of the improvement plan Craegmoor have had to facilitate further reviews with the social care professionals which have started to take place in September 2005. The main purpose being to ascertain how many of the assessed needs originally identified for each person are being met or have been addressed in some way by the home. The Commission has an expectation of significant progress with this and will be commenting on the outcomes of the reviews in future inspection reports. Observations and interviews with care staff showed that there is a discrepancy of understanding of which approaches to care and support are actually agreed in care plans. This is concerning and could compromise the quality of support provided to the residents. Care plans which are based on the assessed needs must be followed by all staff to ensure consistency and to ensure that any difficulties with implementing care plans are identified and addressed quickly. Another long standing requirement from the last report was around providing suitable physical intervention protocols where necessary in line with Department of Health Guidance on restrictive physical interventions and with involvement of a suitably qualified professional. This requirement was based on concerns about how staff responded to aggression and challenging behaviour by service users. From discussions with staff and the manager there was evidence that past restrictive practices have ceased and have been replaced by care guidance which in non restrictive. This is very positive and demonstrates the significance of progress made by the team towards responding more appropriately to difficult situations. Staff have been attending Crisis Prevention Training which covers theories of de-escalation and diversion. However, there was evidence that in some cases the guidance in care plans may not always relate to practice. Evidence of agreed limitations was seen on one file. Risk assessments are another area where further improvement is necessary. These should be linked to care plans to provide a more holistic overview of the support needs. Those seen during the inspection were closely repeating the care plans, but in some cases failed to provide more specific information about how the identified risks would be managed. For example a risk assessment about mobility for one service user stated ‘staff to assist (service user) when walking around the home’. There was no guidance on how this should be done. A staff member explained that they would remove any physical obstacles from Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 13 the person’s way and this is the sort of detail which will make the risk assessment more robust. The Commission has received a complaint from a relative highlighting concerns about the management of service users’ finances. Craegmoor have carried out an investigation into these concerns and provided a response to the complainant. Some discrepancies have been identified for which no satisfactory receipts could be found and Craegmoor has refunded this money to the service users. The complaint has highlighted poor financial management prior to the new manager being appointed in March 2005. Since March 2005, systems for recording service users’ income and expenditure have improved. For one person a care plan about management of finances was seen on file. This is very brief and does not actually specify what support the person requires. Such care plans should cover all aspects of financial management for the individual, including budgeting, saving, spending, understanding of money, ownership / possession of personal moneys, involvement with banking transactions, information about amounts received, appointeeships and so on. The home should consider making the process more transparent by clarifying arrangements for when requests are made by involved relatives to see individual expenditure records for example. Confidential information was stored appropriately on the days of the inspection. However, there still appeared to be some paperwork with service users and staff names on being stored in an unlocked cupboard in the physiotherapy room. This should be stored in a more appropriate place. A recent update from Craegmoor Healthcare provided evidence of placement / monitoring reviews being planned for September 2005 with Gloucestershire Social Services and other funding authorities Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 16. The manager continues to promote access to the community, enabling service users to go out more. Lack of suitable transport continues to be restrictive for service users with mobility needs. Discrepancies between agreed support guidance and staff perceptions in how to best support service users who cannot self-advocate could lead to inconsistencies in approach and compromise people’s autonomy. Service users have opportunities to see their families thus enabling them to maintain these important relationships. EVIDENCE: Day care provision in the home has changed again with less focus on getting everyone to formal activities in the day care room, and looking more at the individuals’ needs and wishes as to how they would like to spend their time. The manager is encouraging key-workers to look for activities and new opportunities outside of the home. Service users have increased opportunities for social and leisure activities and maintain contact with their families. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 15 Staff commented about service users going out more frequently and this becoming part of their daily expectations. During the visit on 2nd September 2005 one service user said they were going to the shops and another person had come back from being out with a member of staff. Daily records were examined for two service users. Records are made about activities, food eaten, support provided with personal care, behaviours and concerns and incidents. However, some daily entries were only partially completed, for example in some instances the record did not specify whether support with personal care was given and who provided this. Records made about behaviour observations did not show who made the entry. These gaps in daily entries could make it difficult to assess whether the care plans were followed consistently and follow up any issues without knowing which staff were responsible for some aspects of care delivery. Records for another person, who spends a lot of their time in the home did not provide sufficient information about how the person spends their time. A staff member explained how behaviours were being monitored for one person. This included recording any incidents of aggression on daily charts and completing a full incident report in cases where other people may have been affected. The staff member advised of involvement from CLDT to monitor these records for triggers and patterns. One service user confirmed that college opportunities were being explored for them. Visit on Sunday 2nd October 2005. The inspectors were able to seek feedback from two sets of relatives who were visiting the home during the Sunday. Service users were clearly pleased to see their relatives and spend time with them. Relatives felt there needs to be more information coming from the home about any changes, such as when keyworkers change. Also about how the welfare of their relatives is being monitored including better transparency about financial matters. One relative wanted to have more information about supporting the service user with a health need during home visits and hopes to join the staff team for a planned training session to increase their understanding of the issues. Overall the relatives felt there have been improvements but more are needed. Staff discussed birthday preparations for one service user during handover. A party was being arranged for the person with music entertainment. During discussion with one family, care staff came into the room to attend to another service user who was asleep. Staff tried to get the person to wake up. This was unsuccessful and the person was clearly indicating that they wanted to be left alone. When questioned about this approach, staff had different explanations as to why it was seen as necessary to move the person there and Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 16 then. None of the explanations given suggested that there was any risk to the service user. Staff told the inspectors that they were not following a specific care plan, but felt what they were doing was necessary to make the person comfortable. There were also contradictions in how staff explained the person was usually supported after having an epileptic seizure. It appeared that the person was likely to need a lot of rest and could stay asleep during the day for some time. On this occasion the inspectors were advised that the person had not long fallen asleep and needed to be changed. An account from another staff member was that the person had been changed not long prior to falling asleep. As a result of the intervention by staff on this occasion, the person was eventually woken, although clearly not as they would have wanted. In addition to this the confidential discussion between the inspectors and the family could not continue, as staff were present in the room. The main concerns for the inspectors following the above observation were around staff approach and intentions and these must be addressed to ensure that service users’ needs and wishes are respected and managed appropriately. A consistent approach must be established and followed when providing any support. Physical touch must be within professional boundaries and agreed care programmes. A requirement for Craegmoor to provide a vehicle in which more than one wheelchair user can be transported has not been met at the time of this inspection. The vehicle has been sourced and should be made available for the home soon. A previous requirement to devise and implement appropriate procedures for supporting service users in and out of the vehicles has not been met to a satisfactory standard. This requirement is repeated in view that with a new vehicle further risk assessments will need to be carried out. Staff spoken with advised that there are currently no risk assessments for taking wheelchair users out for a walk in the community or service users who may display behaviour challenges whilst out. Staff do take their own mobile phones for outings in case of an emergency. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Guidance about meeting people’s personal care needs ensures that this support is given sensitively and respectfully, to protect people’s privacy and dignity. However, some staff are not aware of agreed plans of care and this could compromise the quality of care and encourage inconsistencies. Medication administration procedures and systems are more robust and offer greater protection for service users against medication errors. EVIDENCE: The manager advised that physiotherapy programmes are starting to take place and a number of aids such as walking frames, have been provided to address people’s physical needs, such as postural support and walking. This is very positive but must be closely monitored as staff were not sure who is responsible for co-ordinating these programmes and ensuring these take place. Files for two service users were examined in detail. These contained records of health appointments, such as visits to the GP to monitor epileptic activity. There were also records of weights. It was noted that for one person there was no epilepsy protocol in place, although there was guidance about checking the person frequently at night. For another service user, an epilepsy protocol provided guidance, which was not being followed in practice (as observed during the Sunday visit). Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 18 For the person who displays aggression on regular basis there was no protocol guiding staff on how to respond to this. Staff spoken with confirmed this shortfall. For the same person there was no guidance on how to identify and respond to the service user if they are in pain. Pain could be a significant contributing factor to this person’s aggression and guidance on these issues must be provided. For another service user a traffic light system of describing different behaviours was seen on file. However, the purpose of this guidance was not clear as there was no guidance on what constitutes Red/Amber/Green behaviours. There was also very little in the way of guidance about the specialist needs (mental health) for the same service user. In the same file there was still a reference to slide sheets being used to move the service user dated 10/05/05. The inspectors understood that this practice has discontinued and indeed staff spoken with confirmed this. Irrelevant information needs to be removed from files as this could cause confusion and lead to inappropriate practices. One staff member described a holding manoeuvre used to prevent service users from hitting out when personal care is being provided (holding the persons arms across their chest). Other staff were not aware of this and there was no reference to this on file. The manager needs to check with staff if this practice is used and review the appropriateness of approach. Care plans for people who need support with intimate care tasks should reflect people’s preferences for gender appropriate support. Staff spoken with said there was no guidance about how often a person should be supported with changing for example. They said they would use common sense and observe the person’s body language. The acting manager has again made useful progress with implementing issues identified at previous inspections of medication. The pharmacy inspection showed that requirements made previously had been addressed in a satisfactory manner although in some cases additional action is to be taken following further advice provided by the pharmacy inspector. These requirements appear in this report with timescales of August 2005. Staff have now attended two medication training courses and assessments of competence are being completed before staff are allowed to administer medicines. The specimen signature list of staff authorised to administer medication must be updated to reflect the current situation. Protocols for use of medicines prescribed ‘as required’ have been completed. A protocol for the use of rectal diazepam for one resident requires clarification. The acting manager is to investigate the dose administered on 23rd June 2005 including the dose given and what stock was used. The only stock found was for another resident and a lower strength. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 19 The record book needs clarification of controlled drugs used for one resident on 23rd June 2005, as there appeared to be a missed record when compared with the Medication Administration Record (MAR) chart. Staff have been instructed to date all packs of medicines not supplied in monitored dose system (MDS) packs when first opened to assist with audits. This is not always done but two audits were demonstrated. There was a discrepancy of five tablets in one case, which may indicate the resident had not always received the dose of two tablets as prescribed. Twice daily audit checks of MAR charts and MDS packs are in place and this can now be extended to regular checks (weekly suggested in first instance) on medicines not packed in the MDS blisters. (Sample chart enclosed). Storage and recording of external use medicines has been reviewed. A risk assessment must be written for the only resident where some emollients are left in the room, to ensure the safety and potential risks to this person and to other residents are well managed. Various options for procedures to follow during the actual administration of medicines have been considered along with the potential risks. The acting manager has determined that use of a medicine trolley is not suitable in this care setting but changes have been made to improve the procedures previously followed. The MAR charts are now referred to throughout the process and a plastic container used to hold the medicines for one resident at a time. The container must be lockable in order to be able to secure the medicines in event of an emergency. Various straightforward ways to achieve this were discussed. There must be a written risk assessment for the administration process and written procedures and protocols in place as soon as details of the preferred method are finalised. Other local procedures have been written to supplement the company medicines policy. A number of discontinued medicines are still printed on some MAR charts. Liaison with the pharmacy should ensure these items are removed when the charts are reprinted each month. There is a column to complete for this on the NCR reorder copies of the MAR charts supplied each month and this is perhaps the best way to communicate this information to the pharmacy. The problems of fixing the small controlled drugs cupboard were discussed, as the current method is not suitable. The cupboard purchased is designed as a standalone model and can therefore be fixed to a solid part of the wall beside (rather than inside) one of the other two cupboards (but obscured from the window) using two rag / rawl bolts. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Poor monitoring of systems and care practices in the home as well as problems within the staff team have raised questions about the quality of the service provided for service users and resulted in complaints. EVIDENCE: The Commission is aware of two complaints about the home since the last inspection. One complaint was made directly to the home. This was as a result of miscommunication between the home and the parents of one service user and this has now been resolved. One complaint has been made to the Commission and Craegmoor Healthcare were asked to investigate the issues raised to report on their findings to the Commission and to the complainant. This complaint was made by a relative who raised concerns about poor information about the finances for one service user and the possibility of financial misuse. The concerns were primarily about the financial management systems prior to the appointment of the new manager. As a result an audit of one person’s finances was carried out and this did not conclude that any financial abuse or misuse was taking place. However, some amounts spent could not be accounted for with valid receipts and will be refunded to the service user. One significant amount is still being investigated and if no satisfactory receipt is found, this too will be refunded. These discrepancies could be an indication of poor systems being in operation in the home. Since the appointment of the new manager records of all expenditure are kept and monitored. The Commission understood that a full audit of all service users’ expenditure has been carried out in February 2005. It is then not clear why these discrepancies were not picked up and addressed then. Craegmoor as the Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 21 registered care provider has a duty of care to protect service users from any form of abuse, including financial abuse. Systems for auditing and monitoring service users finances must be robust; these must pick up and address any mistakes and anomalies. The Commission may consider requiring an independent financial audit in the future to assess the robustness of the inhouse procedures. Staff spoken with were confident that they could recognise poor practice and knew how to report this. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 29 Parts of the environment remain unsafe and inappropriate for the needs of the service users, placing them and staff at risk of injury. Work to address these issues has started but improvements will take some time. EVIDENCE: There are a large number of improvements which are required to ensure the home has the facilities and adaptations to meet the physical needs of the service users. Craegmoor Healthcare has allocated a project manager to oversee the works, which will be happening in the home. It may be necessary for service users to move out of the home temporarily to allow for the builders to get on with some more hazardous works. The Commission is being kept informed of the progress. The improvements will include a new extension with the passenger lift and alterations to bathrooms, shower room and at least one communal toilet to include tracking hoists and other aids which will enable staff to support people with physical needs in a safe way. The manager has written to the families to advise them of the proposed changes and pending building work. Feedback from one relative provided evidence that they did not receive such notification. The manager needs to ensure all significant people are notified as necessary. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 23 Work to address subsidence has been completed and the affected lounge has been re-decorated. The dining room has been relocated to the second lounge, and this space is lighter and more flexible, allowing better manoeuvrability for wheelchair users and creating a more pleasant eating environment. Part of the requirement made in the last report about ensuring better hygiene practices in the kitchen has been implemented. However, there has been no consultation with the Environmental Health Department and this needs to be done. It was noted that smell of cigarettes smoked by care staff outside the back door travelled into the main hallway. This makes the communal areas less pleasant for people who do not smoke especially the service users. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Better staffing ratios mean that service users receive more flexible and individualised support. Shortfalls in recruitment practices could be compromising the safety of the service users. Recent investment in staff training should contribute to the development of a more cohesive and competent staff team. EVIDENCE: Staffing requirements and recruitment practices were assessed during the visit on 2nd September 2005 as follows. There were five staff in the home during the morning shift including the home manager. All of the service users were in the home and the majority were just getting up and were being supported with personal care and breakfast. Two staff members were seen to be busy with administration of medication at 8.00 as required and others were supporting the service users. There has been an active recruitment drive during March and April 2005 to ensure that required staff ratios are maintained for the safety and welfare of the service users. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 25 Due to previous concerns, as detailed in inspection report from January 2005, the home has been providing the Commission with information about staff levels every month. The manager explained that after the initial difficulties when several staff had left employment, there is now a more stable staff team in place. The manager advised that due to the high dependency needs of the service users and increased opportunities for community participation she has been planning to increase the levels of staff on some shifts to 7 (seven). There has been a marked investment in staff training since the last inspection with the home providing monthly updates about which training has been completed. Craegmoor have expressed their commitment to developing the skills and knowledge base of the staff in their improvement action plan for Alexandra House. Staff skills and competency will be assessed during future visits. Staff training in fire prevention was taking place on the day of the visit. The manager has ensured that sufficient staff were present to provide continuity of care to the residents whilst the majority of the staff team received the instruction. At least three of the residents were taken out in the morning either for a local walk or shopping. The manager updated the Commission about issues of staff conduct. The Commission will require a formal notification of this when the issues around staff suspensions are resolved. The inspectors also discussed with the manager procedures for referral to POVA. Staff files for several new staff were examined. On the whole these are now better maintained with the majority now having a checklist, ID documents, medical questionnaires and photographs. However, there were still significant shortfalls and these were pointed out the home manager. The main deficiencies identified were as follows: 1. Lack of full employment history (in some cases no employment history completed on application form) 2. No reasons for leaving past employment stated; 3. No evidence of change of terms and conditions or job descriptions, including new staff and those moving to different roles within the home; 4. References obtained from previous employment – from colleagues not from management. In some cases the relationship of the referee to the employee is not clear. 5. Only one reference obtained in some cases. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 26 6. Staff who have moved from other Craegmoor homes – lack of clear documentation of their new roles, reasons for the transfer/ move and start dates. 7. One staff member has started working in the home recently but CRB check seen was from 2003. 8. No evidence of a recent disclosure being discussed with the staff member; 9. Contracts / start dates missing from some files. The above shortfalls are concerning and could leave service users very vulnerable to poor practices from unsuitable staff. These must be addressed and the home must ensure that recruitment procedures are followed at all times. This is an ongoing issue in the home and the Commission may be considering enforcement action if no satisfactory progress is made. The home is also required to clarify the procedures for staff who are transferred from other Craegmoor homes by providing the Commission with a copy of the relevant policy / procedure. Discussion took place about employment of the manager’s close relative in the home. The manager advised that this is on a temporary basis only to provide medication cover. If the arrangement is to remain on a more permanent basis, the manager should consider how this will be managed to prevent any potential for collusion and conflict within the staff team. Previously there were no satisfactory supervisory arrangements in place for care staff. The manager has now had the necessary training and this is also proposed for team leaders. There was evidence that some staff who have been working in the home for over 6 months have not had a formal supervision to date. This must be addressed as necessary. The manager said that she has been monitoring night staff by coming in to carry out an observation during a night shift. One staff member who has been in the home for one month said they were due supervision shortly. Staff spoken with during the October visit were not sure about the diagnosis for some service users. The inspectors were concerned about some staff having sufficient understanding of professional boundaries and about treating people with dignity and respect. These issues followed a specific observation when staff tried to wake up one service user against their wishes. Staff said they do not always have time to read care plans and risk assessments and carry out their jobs as they got to know them. For example staff were not aware of some health issues and communication needs. Epilepsy training has not been accessed by some staff but was scheduled for the near future. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 27 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed. EVIDENCE: The home manager has applied for registration with the Commission. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 28 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X 1 3 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X 2 3 1 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alexandra House Score 2 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000016360.V256800.R02.S.doc Version 5.0 Page 29 YES Are there any outstanding requirements from the last inspection? 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 YA5 Regulation 5,12,17 and Sch 4 Requirement Terms and conditions must be supplied to service users as part of the Service Users’ Guide. These must be fully up-to-date and accurate. (Timescales not met 31/08/04 and 30/04/05) Clarify to service users, their representatives and the Commission (in writing) whether service users have some accumulated savings (from DLA mobility or other payments) held centrally in a Craegmoor operated account. (Timescale of 30/04/05 not met) Care plans must clearly state how each service user’s assessed needs are to be met (including personal care requirements and management of challenging behaviour). (Timescale of 30/06/05 not met) Ensure that care plans are understood and followed by staff and form the basis of practice. (Timescale of 30/06/05 not met) Provide staff with clear guidance on how to respond to difficult behaviours in the home and when out in the community. DS0000016360.V256800.R02.S.doc Timescale for action 31/01/06 2 YA5 5,12,17 and Sch 4 31/01/06 3 YA6 12, 14 and 15 31/01/06 4 YA6 12 and 18 31/12/05 5 YA6 12 and 13(6) 31/01/06 Alexandra House Version 5.0 Page 30 6 YA9 13(4) For use of any restrictive practices there must be a detailed protocol in place in line with the Department of Health guidance on use of restrictive physical interventions. Risk assessments must provide sufficient detail about the actual risks and what specific steps / actions must be taken by staff to reduce or eliminate these. 31/12/05 7 YA9 12 and 13(4) 8 YA12 12 and 16 Risk assessments must be carried out for supporting service users in the community (particularly those who require mobility aids, have serious medical conditions or display challenging behaviours). These must state the numbers and competency of staff required to support the activity safely and any additional measures (such as emergency medication/ mobile phones) which may be used to reduce risks. Robust procedures for supporting 31/12/05 people in and out of vehicles must be implemented to ensure safety of service users and staff, as well as to protect the dignity of service users. (Timescale 02/02/05, 11/02/05 and 30/06/05 not met). Staff must follow safe moving and handling principles at all times. Ensure that more than one 31/12/05 wheelchair user at a time can be transported in then home’s vehicle(s). (Timescales of 30/11/04 and 30/04/05 not met) Appropriate risk assessments must be in place for the new vehicle (s). Service users must be supported to have regular access to DS0000016360.V256800.R02.S.doc 9 YA12 16 (2) 31/12/05 Alexandra House Version 5.0 Page 31 10 YA16 12 activities of their choice and evidence of social, leisure and educational opportunities must be recorded. Staff must ensure that service users’ wants and wishes are respected and responded to appropriately unless there is an agreed written guidance to contradict this. Staff must at all times maintain professional boundaries and ensure that any physical contact with service users is respectful and appropriate. Provide clear and accurate protocols / guidance about people’s physical and psychological health. This must include protocols for managing epilepsy, pain management and mental health needs. Investigate the possible use of restrictive practices for one service user as described in the text. Review the approach and ensure all staff are aware of correct responses to the person. Protocols for use of rectal diazepam to be in place and the correct stock held for each resident. 30/11/05 11 YA18 12 31/12/05 12 YA18 13(6) 30/11/05 13 YA18 13(2) 31/08/05 14 YA20 13(2) 15 16 YA20 YA20 13(2) 13(2) Audits of medicines not packed 31/08/05 in the MDS packs to be carried out regularly and at least weekly. Risk assessments to be written 31/08/05 where a medicine for external use is stored in a resident’s room Medicines to be held securely 31/08/05 during the administration process. Written risk assessments and procedures for the medicine administration process to be completed. DS0000016360.V256800.R02.S.doc Version 5.0 Page 32 Alexandra House 17 YA20 13(2) 17(1) 23 18 YA24 To liaise with the pharmacy to ensure discontinued medicines are not included on reprinted MAR charts. Complete all works necessary to make the environment and facilities in the home safe and appropriate for the needs of the service users, to include refurbishment of bathrooms, shower room and toilets, provision of necessary aids and adaptations, making the garden safe and pleasant for use, providing a new lift to ensure safe and reliable access to first floor. (Project plan has been agreed for the above works.) Carry out consultation with the Environmental Health Department with regards to food preparation and storage in the home. (Timescale of 31/05/05 not met). Ensure all necessary and outstanding records are obtained for all staff working in the home as detailed in the text. 31/08/05 31/03/06 19 YA30 23(5) 31/01/06 20 YA34 19 30/11/05 21 22 YA36 YA22 18(2) 22 23 YA32 13(6) Ensure staff are do not commence employment until full and satisfactory information is available about them. Staff must receive appropriate 31/12/05 supervision. (Timescales of 31/03/05 and 30/06/05 not met) Provide guidance on files about 31/01/06 how each service user is able to express their dissatisfaction and voice concerns. (Timescale of 31/07/05 not met). Provide formal notification to the 30/11/05 Commission about the outcome of staff suspensions including whether referral will be made under POVA guidance. DS0000016360.V256800.R02.S.doc Version 5.0 Page 33 Alexandra House 24 YA34 13(6), 18 and 19 Provide copy of the staff transfer policy to the Commission for reference. 30/11/05 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 YA7 Good Practice Recommendations Care plans about how service users need to be supported with managing their finances should focus on the individual and give the necessary level of detail. There should be reference to any arrangements made with relatives / parents who may be advocating on behalf of the service user in particular how to respond to requests from families to have access to expenditure records. This should be in line with the company policy and communicated to all involved parents and carers. Review storage of information in the cupboard located in the physiotherapy room. Relocate to a more appropriate storage as necessary. Daily entries should be fully completed to provide an auditable reference to care issues, which are being recorded, and to assess whether care plans are being followed. Records should at all times be dated and signed by the person making the record. Improve the quality of communication with relatives / carers/ significant others to ensure people are informed about important aspects of care for their relative as appropriate. Reference to inappropriate use of slide sheets should be removed from care files to minimise potential confusion. Care plans about providing support with intimate care should reflect service users’ preferences with regards to gender appropriate support. The controlled drug cupboard to be secured to the wall as a standalone unit with two rag / rawl bolts in accordance with The Misuse of Drugs (Safe Custody) Regulations 1973. Consider relocating staff smoking area away further from DS0000016360.V256800.R02.S.doc Version 5.0 Page 34 2 3 YA10 YA12 4 YA15 5 6 7 YA18 YA18 YA20 8 YA30 Alexandra House 9 YA32 the house. Staff should have allocated time to read care plans and support guidance on regular basis. Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 35 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexandra House DS0000016360.V256800.R02.S.doc Version 5.0 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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