Inspection on 20/05/07 for Alexandra House

This inspection was carried out on 20th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 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 16/06/06

Alexandra House 28/02/06

Alexandra House 02/09/05

Alexandra House 22/04/05

Alexandra House 11/02/05

Alexandra House 04/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Alexandra House 2 Alexandra Road Gloucester Glos GL1 3DR Lead Inspector Mr Richard Leech Key Unannounced Inspection 20th May 2007 15:20 Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 2 Alexandra Road Gloucester Glos GL1 3DR 01452 418575 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.craegmoor.co.uk Cotswold Care Services Limited To be appointed Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2006 Brief Description of the Service: Alexandra House is a large, detached property in a residential area of Gloucester. The home has undergone a programme of substantial refurbishment and now has 10 bedrooms, some with en-suite facilities. There are three communal bathrooms, additional toilets, a large dining area and a separate lounge. Two of the bathrooms and one toilet have specialist adaptations such as overhead hoists and changing beds. One bedroom is on the ground floor. The other bedrooms are on the first floor. The home has two staircases, and a second lift has been built to improve access between floors. The home has a large back garden which has been landscaped to make it accessible to wheelchair users. The home has a Statement of Purpose which sets out its aims and objectives, as well as a Service Users Guide providing additional information about living in the home. These are available to current and prospective service users and to others with an interest in the home. The base fee was reported to be £1346 per week although this is negotiated on an individual basis. Some additional charges are made, with people living in the home expected to pay for chiropody, haircuts and toiletries, as well as for services such as aromatherapy and reflexology. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Sunday afternoon lasting for about four hours. Further visits were made on the following Tuesday, Wednesday and Thursday, in some cases accompanied by another inspector. The manager was present for the majority of the time. All of the people living in the home were met with along with the majority of the staff team. Some family members were spoken with and/or completed survey forms. Written and verbal feedback was also obtained from health and social care professionals with an interest in the home. General and more structured periods of observation took place during the inspection. A range of records were also checked. These included selected care plans, risk assessments, medication charts, training records, staffing files and certain policies and procedures. What the service does well: What has improved since the last inspection? A manager is now in post and has made progress with addressing some of the shortfalls in the service. Plans are being made to take forward the improvement agenda. This includes offering people more choice and promoting a focus on ‘total communication’. People who live the Alexandra House are being offered the opportunity to go food shopping with the staff as part of increasing their choice about what they eat. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 6 Family members feel more able to raise concerns and complaints and have greater confidence that they will be listened to. There was a feeling that the home was improving and that the atmosphere and quality of care was better. Family and also professionals in the community made positive comments about staff attitudes, knowledge and skills showing some improvements. Some progress has been made with providing necessary training for staff and in enrolling them on NVQ programmes for health and social care. Arrangements had been made to ensure that people with physiotherapy exercise programmes were supported to follow these each day. Related to the above, the home had started working with the local Community Learning Disability Team again, who withdrew following concerns about communication and the standard of care in the home. Whilst there is further work to do, a more constructive relationship is being forged. Reports made following monthly unannounced visits by the area manager are being forwarded to CSCI. Some further improvements have been made to the physical environment. This includes providing a private area for people living in the home to meet family members. What they could do better: Care plans do not fully and accurately describe how people’s needs, wishes and goals are to be met. Care planning in the home is not sufficiently personcentred. Many of the people using the service do not have enough to do and are offered little choice about how they spend their time. Much work needs to be done around communicating effectively with the people living in the home. This should help to give them more of a voice, allowing them to have greater choice and control over their lives. There are systems for checking the quality of the service, but these had not picked up many of the shortfalls in service provision identified in this report. There also needs to be more emphasis on seeking feedback from people living in the home and their representatives. Risk assessment and management in the home is inadequate, increasing the likelihood of inconsistent or inappropriate practice. There needs to be more vigilance about keeping confidential information secure. Although people’s personal and healthcare needs are generally being met, there is scope to improve aspects of practice including having more a focus on how people prefer to be supported. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 7 Similarly, some improvements are needed to elements of the way that medication is handled to make the systems more robust. Poor practice in the handling of service users’ finances was increasing the risk of harm and abuse and was resulting in people being out of pocket. Whilst there has been extensive refurbishment of the home, some shortfalls were found with the environment. Some areas had offensive odours, and some cleanliness, maintenance and hygiene issues were highlighted. One en-suite facility was not fully operational due to drainage problems. There was evidence of progress being made with areas such as staff training, knowledge and skills. However, some issues were identified around attitudes and values, sickness levels and specialist training. In addition, some major shortfalls were found in procedures for recruitment and selection and in the formal support and supervision that staff receive. There appeared to be significant issues around team cohesion and dynamics which required attention. Whilst some improvements in management were evident there were some areas, summarised above, which needed more attention. It is acknowledged that the service acted swiftly to address some of the shortfalls identified in the inspection following receipt of the draft report. However, action is being considered by CSCI in respect of ongoing serious shortfalls which have been identified in previous inspections. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that people considering moving into the home receive the information that they need to make an informed choice. A framework exists for referral and assessment which should help to ensure that people moving into the home will have their needs appropriately assessed. EVIDENCE: People’s files included copies of the Statement of Purpose and Service Users Guide, although some of the information was outdated. The manager said that the Statement of Purpose had been forwarded to head office for revision. Following the inspection copies of the updated Statement of Purpose and Service Users Guide were sent to CSCI. These appeared to be satisfactory. The home had one vacancy at the time of the inspection. The manager said that there had been some referrals and that she had been to visit two people. Some assessment and background material was seen in respect of one referral. Whilst the process was still at an early stage the information seen was detailed and relevant. It was agreed that, should this progress, an up to date community care assessment should be obtained. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 10 The person was due to make a short visit to the home later that week. The manager confirmed that the admissions procedure would usually include introductory visits and overnight stays. It was agreed that a record should be kept of each visit as part of the admissions process. The manager confirmed that compatibility with existing residents would be considered through assessment as well as through monitoring interactions during visits. On the basis of the above, Standard two is assessed as met. As with all services, actual practice around admissions will be considered during future inspections in the event of somebody moving into the home. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans still do not fully and accurately describe how people’s needs, wishes and goals are to be met, increasing the risk of inconsistent or poor practice. Arrangements for supporting the people living in the home to express choices and wishes are inadequate, particularly in respect of people with limited or no verbal communication. This may result in people feeling disempowered and denied a voice. Continuing shortfalls in some aspects of risk assessment and management may result in inconsistent or inappropriate practice. EVIDENCE: The manager said that a new care planning system was being introduced by the organisation and that this was much more person-centred. The organisation was said to have set a deadline of the end of September 2007 for Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 12 implementation. Whilst this should be a positive development, it is necessary to comment on the care plans in place at the time of inspection. Two people’s care planning files were checked in detail. The following observations were made: • • Some basic information was outdated such as the manager’s name and certain details in profiles and pen pictures. Some assessment material contained inappropriate or inaccurate statements such as, “will try to be awkward with certain support workers”, “…unable to communicate” and “Can be stubborn and uncooperative”. Other comments were written which required further description and exploration such as self-esteem and confidence being assessed simply as ‘good’ with no further development. Some documents in care planning files were undated and/or had no recorded author. Certain care plans were seen to contradict themselves such as, “I am unable to assist with any aspect of personal care…I will participate when dressing myself.” Care plans seen about communication were inadequate, containing only a few general notes such as, “I communicate with facial expressions and gestures”. Some referred to tools such as flash cards which were not being used. Although most care plans were seen to be reviewed every month, some had not been reviewed between August 2006 and May 2007. Some care plans were clearly outdated, referring to practices which the manager said had ceased, such as carrying one person up the stairs when certain behaviours were expressed. However, the plans remained on file as if ‘live’. Actions described in some assessment and care planning material were not happening. One person’s assessment noted that “it is essential to carry out my physiotherapy programme” but the person was reported to have no such programme in place. • • • • • • Some care plans were seen to provide reasonably clear and practical guidance about how to support people, and included reference to the person’s preferences. Some person-centred work had been done in the last although this was patchy and in need of review and update. The manager said that referrals had been made to the Community Learning Disability Team in respect of communication. She hoped to place a much greater emphasis on this area, supporting the team to look more broadly at how each person communicated. The manager reported that intensive interaction was not happening as such, though was hoping to increase the amount of one to one time that was offered to the people living in the home. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 13 Examples of daily records were looked at. As these were loose pieces of paper they were hard to track through and on certain days of the inspection some of them could not be located. It was suggested that the team look at introducing a bound recording format so that daily records remain in sequence. Some moving and handling protocols were seen. Some were undated and there was no evidence of review. Staff descriptions of practice for supporting one person to transfer to and from their wheelchair differed slightly, indicating that a clear protocol needed to be written. It was also agreed that clear guidance needed to written in respect of the same person for the use of a helmet as, again, staff accounts of when this was used varied. Guidance was also needed about the use of a belt attached to the person’s easy chair to ensure that it was used purely for safety rather than as a form of restraint, with the way that the person communicates that they want to leave the chair being clearly described (reported by healthcare professionals to be indicated by rocking). At some points during the inspection very close physical contact between staff and service users was seen, including hugging and stroking. Some staff were asked if there was any guidance about physical contact and replied that they were not aware of any. This issue should be considered during the forthcoming care planning exercise in order that there is clear guidance about what is appropriate and where boundaries need to be drawn. Issues around choice were considered under standard 7. Whilst some people were seen making choices this tended to be the people who were able to verbally communicate their wishes. It was agreed that there was scope for considerable development around decision-making and choice. This particularly relates to the absence of appropriate care plans and guidelines about communication and to total communication approaches having not yet been implemented to any significant degree. In addition the manager also agreed that advocacy for all service users should be explored, and she was already investigating local provision. The manager was aware of the new IMCA (Independent Mental Capacity Advocate) service and of the possible need to call upon this in certain situations. It was reported that staff had not yet had any input about the Mental Capacity Act. This should be provided before the majority of the act comes into force in October 2007, given the extent to which capacity, consent and best interests pose day to day challenges in the service. Some staff commented on people living in the home not always being offered as much choice as they should be, with decisions being made for them instead. It was acknowledged however that questions around choice present significant complexity given the service users’ needs and conditions. This issue relates closely to that of communication described above. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 14 Risk assessments for two people were looked at. These were seen to link closely to care plans. Some provided guidance about activities in the community and use of transport, with reference to the numbers of staff required to provide support. Certain assessments had been recently reviewed, although some had no documented review since July 2006. Some of the measures described were inconsistently applied. For example, a risk assessment about communication reported that all staff would receive makaton training but discussion and records showed that some staff had not. Some of the interventions described on risk assessments were unclear. For example, one stated that staff were to ensure that the person received regular exercise without describing how this should be done (the person had very complex mobility needs and no physiotherapy programme at the time). The manager reported that risk assessments were under review but that they would be completely rewritten as part of the introducing the new care planning formats. Following the inspection it was confirmed that risk assessments would be updated by September 2007. Some staff expressed anxiety about taking one person too far away from the home due to the risk of seizures, indicating that work needed to be done on risk assessment in this area. See comments on epilepsy protocols later in the report. Protocols were seen around the use of the lifts. Standard 10 was not inspected in full. However, some completed daily entry sheets were found in the lounge as well as the communication book. These contain personal information and need to be stored securely. Following the inspection the manager reported that all staff had been reminded about this. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Activity planning in the home does not fully respond to people’s needs and interests, impacting on their quality of life and inclusion in the local community. Appropriate support is provided to enable service users to stay in contact with important people in their lives. The home’s ability to respect people’s rights is compromised by shortfalls in areas such as care planning and approaches to communication. This can result in people not being ‘heard’ and their choices and rights being restricted. People living in the home are offered a reasonably balanced diet and plans to improve choice and nutritional content should further promote people’s health and enjoyment of their food. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 16 EVIDENCE: During the inspection people were seen being supported to go out, for example to shops, with family or to a day centre. Care plans seen about activities listed people’s likes and dislikes but without giving clear structure or guidance. Staff spoken with also commented on a lack of structured activity plans for people saying that, aside from certain regular activities for some people, arrangements tended to be ad hoc. Many staff expressed concerns at what they saw as poor activity provision, and of this being the case for some service users more than others. The majority of staff felt that people in the home generally did not have enough to do, particularly some people who had difficulty communicating or who did not have family involved. Comments were made about over-reliance on television and music/’karaoke’. Similar concerns were expressed through feedback from family members. Daily records were checked for two people. For one person the majority of entries made reference to TV and music in the lounge. According to records they went out on trips on only three occasions over the 13 days, with a period of six successive days without leaving the home (besides using the garden). There was reference to regular aromatherapy massage in the home. Assessments referred to the person enjoying swimming/water-based activity but staff confirmed that this was not taking place. A letter from a healthcare professional (11/12/06) made the comment, “[service user] has no formal programme of activities…would benefit from swimming.” The person’s specialist mobility needs mean that providing this activity would require careful planning and assessment. However, it was agreed that there should be a renewed impetus to arrange this in conjunction with relevant professionals in the community. The manager understood that the person was on a waiting list for hydrotherapy and said that she would chase this up. A second person’s daily records were sampled for nine days (three entries could not be located, making a full sequence for the period impossible). These entries indicated that there had been only one trip out of the home (for shopping), with most entries making reference to TV and music as well as occasional aromatherapy and other activities in the home and garden. A review by the placing authority from late 2006 was documented. It had been agreed that a team leader would be working towards implementing a full programme of day services by the next review in June 2007. Records, observation and discussion with staff indicated that this had not been achieved. Records on one person’s file indicated that they had certain spiritual needs. Staff described how these were met. However, the home’s care planning file and the placing authority assessment ascribed different religions to the person. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 17 The manager and deputy confirmed their intention to create more structured, individual activity programmes as part of the person-centred work due to take place. The above is evidence of the need to move forward with this urgently in order to improve people’s quality of life. Following the inspection examples of activity plans were submitted. Actual practice in this area will be checked during forthcoming visits to the service. The home had three vehicles, though at the time one was on loan for a week and another had been stolen. The manager said that she hoped three vehicles would again be available a week or two after the inspection. She reported that there were seven drivers, but that she was looking to increase this number further. The manager said that there were no extra charges made to the people living in the home for transportation. The manager stated that the organisation gave an allowance of £200 per person per year for a holiday. Consideration was being given to making individual arrangements for holidays or, where more appropriate, day trips but nothing definite had been arranged. It is recommended that this be taken forward given that it is nearly half way through the year. Over the course of the inspection many of the people using the service were visited by family, went out with them for the day or stayed at the family home. Daily records provided further evidence of people being supported to maintain contact with family. Some family members provided written or verbal feedback. In general there was a feeling that the home was improving and that concerns raised in the past were finally beginning to be addressed. People expressed more confidence in the quality of the care their relative was receiving and also in being listened to if they raised a concern. There were positive comments about the way that the home kept them informed about issues compared to how this had been in the recent past. However, concerns were still expressed about having to repeat requests several times before this was communicated throughout the staff team and implemented. One person whose care was looked at in detail used to visit their former home in Bristol but had not done so for some time. The manager said that this would be arranged again. Standard 16 was considered. Some positive practice around people’s rights was observed or evidenced in daily records and discussion with staff, such as people going to bed at times of their choice. However, as noted, people’s rights to be consulted about their activities, to become part of the local community and to be offered choice in general are compromised. The introduction of more person-centred planning and a focus on total communication should help to improve outcomes in this area. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 18 People were generally seen to move freely throughout the home, with some areas being locked due to health and safety risks. However, as described earlier one person’s rocking in their easy chair was reported by healthcare professionals to be a sign of wanting to get out of it but care plans and observed practice in the home did not accord with this principle. The manager was aiming to introduce more choice about food for the people living in the home. As part of this they were being invited to join staff on foodshopping trips in rotation. The manager was also trying to work towards people’s diets being more nutritious, saying that there sometimes over-reliance on snack foods such as tinned spaghetti. Service user surveys provided evidence that people living in the home did not always feel that they had much choice about what they ate. During one evening a takeaway meal was provided for people. On another night a birthday cake had been prepared for one of the people living in the home. Records were seen of the food that each person consumed. This provided evidence of a reasonable balance and variety. Samples of menus were also checked. Some mealtimes were observed. The atmosphere was seen to be relaxed, with people appearing to enjoy their food. The home employs a cook. A certificate was on display confirming that they had been on a food safety course in April 2007 to update their knowledge (though see comments about the kitchen in ‘environment’ part of the report). The cook said that alternatives were provided if a person didn’t want what was on the menu for a particular day or if they had dietary needs necessitating an alternative. Staff confirmed that this was the case, giving examples and demonstrating knowledge of issues such as food allergies. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 19 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst people’s intimate care needs are being appropriately met there is potential for improvement to aspects of the service in order to further promote the quality and consistency of personal care. People are generally accessing the healthcare services that they need but some shortfalls in this area may put elements of people’s health at risk. Arrangements for the handling of medication are generally satisfactory, but there is scope to improve some aspects of this to promote people’s safety. EVIDENCE: People were seen to receive prompt personal care when needed or requested. Service users were observed to be smartly dressed in clothes appropriate to their age. Staff confirmed that people living in the home went clothes shopping and that their tastes were ascertained as far as possible (though see earlier comments about progress that could be made with ‘total communication’). People were seen having sun cream applied before going out on a sunny day. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 20 Daily records provided evidence of people receiving personal care at various times during the night. The manager described arrangements for checking people at night if necessary, and said that she had introduced an observation chart. Some comments about personal care at night were relayed to the manager for consideration. In addition the quality of handover to the day staff was discussed. Some entries in the communication book (used for handover purposes) were rather general or confusing such as, ‘Fine. No concerns’ and ‘Very agitated. Slept well. No problems’. Some observation records were seen. One such record did not state who was being observed. Family members spoken with felt that their relatives were receiving appropriate personal care. A protocol was seen for the use of a baby monitor. The manager said that a vibration-sensing mattress had been discontinued after consultation with the CLDT as it had not proven to be effective. Protocols about epilepsy were seen for one person. However, these were undated and discussion with staff indicated that practice varied between staff and differed from the protocol. It was agreed that this was in need of revision. As alluded to earlier, some staff also expressed a lack of confidence about taking the person further afield on a trip due to their seizures. This suggests that a clear protocol related to risk assessment and external guidance was necessary as part of promoting a fulfilling activity programme for the individual. The manager was arranging training about use of a rescue medication for staff in June. Following the inspection copies of revised and updated epilepsy protocols were submitted to CSCI. As noted, some care plans made reference to people’s preferences in areas such as personal care though there was significant scope to improve this. Records in people’s rooms provided evidence of physiotherapy exercises happening each day. Staff confirmed that the Community Learning Disability Team had provided training about this. There was some question about whether another service user needed a regular physiotherapy routine. The manager had understood that a reassessment was due to be made about this but information was received to the contrary, indicating that the service needed to consult with the CLDT about this issue. Healthcare records for two of the people living in the home were looked at. There were significant gaps in the records of chiropody appointments, in some cases from August 2006 to February 2007. The manager was able to produce other evidence that people had received a regular service. It therefore seemed Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 21 to be a recording issue. In addition there seemed to be two different places for recording healthcare appointments, with some being recorded in health action plans and others in general healthcare notes. Records suggested that one person had been waiting for a dental appointment since at least October 2005. Staff confirmed that the person was apparently on a waiting list. It was agreed that this need chasing up urgently. It was also another that person needed their oral health checked as there were no records of this being routinely accessed. Records of weights were checked. In some cases these were in different units of measurement. It is recommended that the staff stick to one system to make comparison easier. Letters and discussion with staff provided evidence of significant input from the Community Learning Disability Team, including detailed recommendations and some training. Examples of health action plans were seen on files. However, whilst some good work had been done the examples seen needed review and update. Other than recording of some appointments there was no evidence that they were ‘live’ documents. Some feedback was obtained from healthcare professionals with an interest in the home. Whilst there was positive feedback, concerns were also expressed about the home operating in a slightly disorganised manner, with important issues not always being communicated throughout the whole staff team and recommendations not being consistently followed through. An example was given of practice which could have put one person at risk, related to lack of staff awareness of issues around mobility. One person was taken to A&E for a check during the inspection. Arrangements for handling medication were looked at. In general storage and recording were found to be in order. The following observations were made: • • • One preparation was not marked with the date of opening. External and internal medications were not separated. PRN protocols were found in different locations rather than being accessible in the file containing administration records (where the manager understood that they were kept). Some examples seen appeared not to have been reviewed since May 2005 and would benefit from review and (if necessary) update. Whilst most handwritten entries were signed and countersigned some needed the author’s signature and that of a second person checking the entry. • Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 22 • • It appeared that staff made an error recording the date of administration of some PRN diazepam for one person as on one side of the sheet it was recorded as April 24th and on the reverse as the 25th. This suggests that greater vigilance is needed. One person was receiving some medication covertly. The organisation’s policy on this notes that it should be in exceptional circumstances and subject to risk assessment, with all relevant professionals’ agreement documented. Such documentation was not found. Staff spoken with confirmed that they received training about the safe handling of medication from the supplying pharmacy. A list of staff authorised to administer medication was seen. Arrangements for booking out medication were seen to be satisfactory. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 23 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements for handling concerns and complaints are in need of review. Plans to promote ‘total communication’ in the home should help service users to have more of a voice and to express any concerns and complaints. Poor practice in the handling of service users’ finances increases the risk of harm and abuse and is resulting in them being out of pocket. EVIDENCE: In the last report a requirement had been made to provide guidelines of each person’s file about how they express dissatisfaction and voice concerns. This was found not to have been met, but has been incorporated into the requirements about care planning. Different versions of the complaints procedure were seen around the home, many referring to people who no longer worked for the organisation or who were in different roles. The manager reported that she had asked for an updated and more accessible version of the complaints procedure to be produced. Copies of updated complaints procedures were forwarded to CSCI following the inspection and appeared to be satisfactory. The pre-inspection questionnaire noted that two complaints had been made to the home in the previous 12 months. However, there was no complaints log, with the relevant documentation being in different locations or not available. The manager was not sure what the second of the two complaints had been, Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 24 illustrating the need for a central complaints log with information about the complaint, investigation and outcome, with any actions arising. Following the inspection it was reported that a book had been obtained for logging complaints and outcomes. This will checked during future visits. As noted, family members spoken with expressed greater confidence about raising issues and being listened to. Financial records for two people were checked. The manager and deputy manager control access to cash and record each transaction, signing to book in the receipt. The manager said that the people living in the home are, in effect, given a loan from petty cash for their spending which is then reclaimed from their account operated centrally by Craegmoor. The following points were made about the records seen: • One person had been charged £11.77 on 20/03/07 for what appeared to be four drinks, including at least one that the person would almost certainly not have consumed. This indicated that they covered the cost of accompanying staff members’ drinks. Another person had been to the cinema and a fast food chain on 09/05/07 but no receipt had been obtained for the £18 spent (“No receipts issued” was written). This appeared quite high for a cinema ticket and a fast food meal, and it may be that the person had covered the costs of the accompanying staff member(s). It was agreed that it should have been possible to obtain receipts from such venues. Staff must always bring back proper receipts unless it is absolutely impossible to do so. For the above transaction £20 had been taken out for the person but the £2 change had not been added to the running total. They were therefore out of pocket. A receipt for the same person dated 18/03/07 for £3.18 was headed as drinks for two service users but one person had covered the total cost. The manager suggested that on a social outing it was normal for one person to buy drinks for another. However, it was agreed that the person in question would lack the capacity to consent to this. The same person had two receipts dated 18/03/07 for £9.90 and £20.15 and had been charged for both. These were all for transactions at lunchtime and appeared to be for three meals, again indicating that the person had covered the costs of accompanying staff at significant cost. • • • • Some staff said that the home covered the costs of their refreshments when accompanying service users by sums being reclaimed through petty cash. The manager was not sure of the policy but later established that a working party was looking into this issue across the organisation. In the meantime there was a clear lack of understanding about the approach to take, resulting in service users paying these costs, in some cases totalling significant sums. Lack of a clear policy increases the risk of financial abuse. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 25 All of the above cases must be investigated and refunds issued if necessary. The policy about covering the costs of food and drink for accompanying staff members must be clarified and consistently applied. Following the inspection it was reported that the above cases had been investigated and refunds issued where appropriate. Documentary evidence was supplied in respect of some (though not all) of these transactions. An updated Statement of Purpose and Service Users Guide were submitted including reference to charging policies. It was reported that all food and drinks costs for staff members accompanying Service Users would be covered by the Company. A wider audit of all service users’ financial records must be undertaken to check for cases where service users have covered costs which the home should have covered all or part of, or for situations where a lack of vigilance has resulted in them being out of pocket. Following the inspection it was reported that this would be done. Receipts must always be obtained for all transactions unless it is impossible to do so. The manager was reminded that she and the deputy sign to record that in their view a transaction is sound. Examples of records relating to the centrally held accounts for service users were seen, covering a 12-month period. There was no reference to any interest being accrued, although it has been stated in the past that people do receive interest on the money held in such accounts. This will be checked with the organisation. The manager reported that restrictive physical intervention did not take place in the home. No incidents of restrictive physical intervention were observed or referred to on records checked. The service has a policy on whistle blowing dating from April 2007. There is a comprehensive policy about the protection of vulnerable adults from December 2006. The manager was not sure if they had a copy of the local adult protection procedures in the home. If not, this should be obtained. Staff spoken with demonstrated an understanding of adult protection issues and confirmed that they had received (in-house) training on the subject. Some issues were passed to the manager for investigation and it was agreed that the outcomes would be fed back to CSCI. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. In general an appropriate environment is provided for the people using the service. However, some shortfalls in certain parts of the property and in hygiene standards could compromise people’s safety and comfort. EVIDENCE: In the last few years the home has undergone extensive renovation and redecoration. This has resulted in a significant improvement to the physical environment including in provision of appropriate aids and adaptations. On some days of the inspection the lounge smelt strongly of urine, particularly on the first day (20/05/07). The manager said that new carpets were going to be provided in various parts of the home, partly to combat the odours. The lounge carpet was in a particularly poor state, with heavy staining. Following the inspection the manager reported that a new settee had been ordered for the lounge and that an odour neutraliser was being used to help Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 27 combat offensive odours. It was also reported that a new lounge carpet was on order. Documentary evidence was provided for the above. Two chairs in the lounge had dried, encrusted food on them. A room had been set aside for visitors so that they could meet people in private. The manager said that she planned to turn the current ‘day room’ into more of a second lounge, with new furniture and soft furnishings. Bedrooms were seen to be pleasantly decorated and personalised. One person had moved into a larger room to facilitate giving personal care. Their former room was now an area for staff. One person’s en-suite facility was not fully operational. Water was said to drain incorrectly, risking floods in the room below. As well as being a wasted facility, this was resulting in the person having to access communal bathrooms, increasing the pressure on these resources. A relative commented on the lack of a soap and paper towel dispenser. The manager said that this would be provided and that the contractors were being chased up about the drainage. Following the inspection it was reported that contractors were scheduled to sort out the issues with the en-suite facility imminently. In previous inspections it has been noted that just one hoist was available. The manager confirmed that a second had been ordered and that a third (a model with a weighing facility undergoing trial) would also be provided by the supplier. Following the inspection evidence was forwarded of this issue being addressed. On 20/05/07 at 15:30 parts of the kitchen was found to be in an unacceptable state. Some food and a pan of gravy had been left exposed and the window was open. The sink was dirty, with remnants of the previous meal not having been cleaned away. A carton of fruit juice was labelled as having been opened on May 10th. The instructions said this should be used within four days but the carton was still in the fridge 10 days later as if for use. It was later clarified that the kitchen windows were new and that fly screens were on order so that ventilation could be achieved without compromising food hygiene. New chopping boards, knives and worktops had also been provided. Aside from the points noted above the rest of the home appeared clean, fresh and hygienic. A cleaning schedule was submitted following the inspection. The manager stated that the state of the kitchen as described above was not the norm and was due to a staff member having been called for a meeting. Staff described some of the measures in place around infection control including regular washing of slings. The manager said that she was aware of Department of Health guidance about laundering of slings. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 28 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Progress has been made towards the team becoming more competent and qualified, but further work needs to be done to promote the quality of care. The effectiveness of the staff team, and therefore the standard of care, is being compromised by a number of factors such as high sickness levels. Shortfalls in recruitment and selection procedures could put people living in the home at risk. Staff generally receive the training that they need, helping to ensure that they can provide appropriate support for the people using the service. EVIDENCE: Staff spoken with demonstrated an understanding of people’s needs and conditions when asked about specific issues referred to in assessments and care plans. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 29 Family members spoken with commented on an improved atmosphere in the home, partly relating this to a more stable staff team with greater knowledge of the people they supported. Some structured observation was completed for about 1.5 hours. In general interactions between staff and service users were seen to be positive, with skilled and sensitive interventions. In some cases it was noted that staff performed actions without explaining to the person what they were doing/about to do and why, such as putting on one person’s helmet or moving a person in a wheelchair from behind. During more general observation throughout the inspection interactions were seen to be appropriate and supportive in the majority of cases. However, a staff member who had just assisted one person with an aspect of personal care was heard to say, “I just sorted you out – what are you moaning about now?” when the person attempted to communicate something. Whilst this may have been seen as humorous or bantering, it presented as disrespectful to the service user. At the time of the inspection the manager produced figures indicating that about 30 of the staff team (of care workers) had relevant NVQs at level two or three. However, she reported that nearly all of the remaining staff were being put forward for NVQs. The rota provided evidence that staffing levels of 6 or 7 were being aimed for per shift, with the manager and deputy as supernumerary. The manager said that staffing levels were never allowed to fall below five, unless significant numbers of people were staying away with family. However, high sickness rates were having a major impact on day-to-day staffing levels, with numbers often falling to five as a result. Staff work a 13-hour shift with a one hour break. Many commented that, as well as being exhausting, they did not always feel able to take a break as this may leave only four on shift (if there was staff sickness that day) and impact on areas such as activities. The manager said that she would like to change the shift patterns but that this depended in part on filling the vacancy (the home was able to accommodate one more person). Some staff said that they liked the longer shifts as it resulted in more days off. The manager said that she was going through procedures and working with Human Resources to address issues around high sickness rates. It was clear that this issue was impacting significantly on the quality of care and on team morale and motivation. In addition to the above there were a number of issues identified around dynamics in the team(s). It was agreed that these needed to be addressed before they became further entrenched. Unpicking and resolving the issues Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 30 may require more direct intervention from senior staff within the organisation, both supporting the manager and working with the staff individually and as a group. The manager described the approach to recruitment and selection. She had been working with Human Resources, including in some cases requesting that they form part of the interview panel. Four staffing files were checked. The following observations were made: • • • In one case dating from November 2006 a second reference had been obtained after the person had started work in the home. The same person had no application form on file, and was therefore missing information such a full employment history. There was also no statement by the person as to their mental and physical health. One application form showed a gap in employment from October 2005 to June 2006 with no account given on the form or elsewhere on file. The same person had named referees from jobs which had not been declared on the application form. References obtained appeared to be from different sources to those named in any case. There was discussion of an issue relating to one person’s previous employment. It was agreed that a full account of the issues and the outcomes needed to be written up and kept on file. • Interview notes were not always being retained in the home. It is recommended that these be kept to hand. More recent recruitment had shown an improvement in practice. Following the inspection that manager reported that there had been an audit of staffing files. Staff expressed general satisfaction with the training provided by the organisation. Training records were checked. These and the communication book indicated that staff were accessing a wide variety of courses, both mandatory and specialist. Training records were individualised. The manager explained that some certificates had not yet come through from some completed courses. A training matrix was being complete to indicate any gaps in provision. Some people had been identified as requiring certain mandatory training and there was evidence that this was being booked. The manager reported that she provided some basic training about epilepsy, having obtained a diploma in epilepsy care. Discussion also showed that a specialist in the community was providing some input for the team. There was a discussion with the manager about the possibility of arranging further specialist training related to the needs of the people living in the home, Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 31 such as about tissue viability and autism. As noted, some input should be provided about the Mental Capacity Act. It was not clear who had completed training about supporting service users with physiotherapy exercises, as the manager had no record. It was agreed that this needed to be obtained in order to be sure of who was trained to provide this input. Newer staff spoken with expressed general satisfaction with their inductions. As well as shadowing and being introduced to the service, there is a formal written element which follows the Common Induction Standards. However, one person who had started in the home more than two months previously had not received their formal induction file to work through since it had not yet been sent from the regional office. Ideally a more service specific induction which meets the LDAF standards should be made available to staff. Standard 36 was not fully considered. However, the manager said that team leaders, who have responsibility for supervising support workers, had not always kept on top of this. Further evidence of this shortfall came from a relatively new staff member (start date August 2006) reporting that they had not had a formal supervision meeting at all in 2007, one having been cancelled earlier in the year. Following the inspection the manager reported that a new staff supervision timetable had been produced. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 32 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Aspects of the service are being well managed, resulting in some improvements. Considerable work is still needed to bring the service up to the level required to meet service users’ needs consistently and comprehensively. There are systems for checking and improving the quality of care provided, but more emphasis is needed on obtaining feedback from the people using the service so that they have more of a voice. Arrangements for monitoring health and safety help to safeguard the people living in the home. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 33 EVIDENCE: The manager joined the team late in 2006. At the time of the inspection the manager was not yet registered, though steps to get this underway were said to be imminent. The manager is a registered nurse with a background in supporting people with learning disabilities living in the community. She reported that taking on the running of the home had been a major challenge, but that she felt that the service was beginning to improve. She had asked for some administrative support in view of the volume of paperwork and organising to do. The manager said that she received support and regular supervision from her line manager, as well as informal peer support from other home managers. The manager said that she was waiting to begin the Registered Manager’s Award, adding that the deputy manager would be undertaking this as well as the NVQ level 4 in health and social care. Family members spoken with were positive about the manager, saying that there had been a marked improvement in the atmosphere and the standard of care. Some concerns were expressed by staff about information provided to the manager in confidence being leaked, both to the deputy manager and to other staff. There were also concerns about personal information such as details of sickness records being made available. This was put to the manager, who felt that this was not the case but reported having put in place additional measures to ensure that confidential information did not become known within the wider team. The manager had been in post for a relatively short period of time and could not have been expected to address all of the issues impacting on the service. As described, there was evidence of some improvements. There was also evidence of action being taken to further improve the service, such as ordering of another hoist. However, as is clear from the report, there remained much work to do and some management weaknesses needed to be urgently addressed, such as concerning service users’ finances. It was noted that an old registration certificate was on display in the hallway, with a former manager named. This needs to be replaced with the current certificate stating ‘manager to be appointed’ which had been generated by CSCI in March 2006. The organisation has a series of different quality assurance audits covering areas such as health and safety, food safety and finances. Some are completed Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 34 internally by the manager whilst others are undertaken by a visiting team. On one day of the inspection a team had come to check health and safety. An overview audit was seen dated 28/03/07. This was very detailed, covering a wide range of areas. The home achieved a score of 90 . An action plan was meant to be created although this appeared not to have been done. The manager reported that there had been an unannounced audit by the Clinical Governance section on 27/04/07 and that she was awaiting a report of their findings. A medication audit had been completed by the supplying pharmacy on 17/04/07, with no significant issues being uncovered. Regulation 26 reports are being forwarded to CSCI regularly. The organisation has a forum for people using the services, with representatives from different homes, although at the time there was no direct input from any of the people living at Alexandra House. An event related to this was planned for June 2007 and a ‘Your Voice’ facilitator had been nominated to cover the geographical area which includes Alexandra House. Whilst arrangements for quality assurance appear thorough, it was agreed that there was scope to develop input from the people living in the home and their representatives. Plans to focus on alternative communication strategies, with help from speech and language therapy, should help with this process. Person centred planning will also have a role to play in providing people with opportunities to feed back about their care. Given the number of shortfalls uncovered by the inspection, questions could be asked about the effectiveness of the quality assurance tools and/or the way in which they are being implemented. Health and safety was considered. The visiting team, from a consultancy contracted by Craegmoor, reported that they had no significant concerns having checked a number of records and looked around the home. Staff spoken with indicated that they had no major concerns about health and safety, although some people said that fatigue related to long shifts may increase the likelihood of errors, for example with medication. As noted, there are internal audits which cover health and safety issues. The manager said that she had undertaken an externally accredited health and safety course. Staff also receive some input about health and safety issues during induction and ongoing training. The maintenance book was seen and provided evidence of a good system for reporting and dealing with issues around the home. Records of various routine checks undertaken by the maintenance person were seen. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 35 It was reported that the door from the area used for administration (just outside of the main office) through to the corridor was a hazard as it was not possible to tell if somebody was coming through in the other direction. The manager was hoping to have a pane of glass fitted to address this problem. Following the inspection it was reported that this had been done. Examples of risk assessments and records of checks for bedrails were seen. The manager and maintenance person were aware of recent safety bulletins about these. Fire safety records viewed appeared to be in order, though it was noted that the last fire drill had been on 12/02/07. The names of people present for the drills were not being recorded. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 36 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 2 34 1 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 x 1 x LIFESTYLES Standard No Score 11 x 12 1 13 1 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 2 x x 3 x Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 37 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 13 (5) 15 (1) 17 (1) a. Sch. 3 (3) (l) Requirement Timescale for action 30/09/07 2 YA9 13 (4) 3 YA12 16 (2) m &n 12 (1) 13 (6) 17 (2) Sch. 4 (8) & (9) 4 YA23 Care plans must clearly state how each service user’s assessed needs are to be met (including personal care requirements, management of finances, communication, moving & handling, physical & mental health, use of equipment and management of challenging behaviour). Timescales of 30/06/05, 31/01/06, 31/05/06 and 30/09/06 not met. Assessments of risk must be up 30/09/07 to date, clear and consistently applied. They must provide sufficient detail about the actual risks and actions to manage these. Timescales of 31/12/05, 31/05/06 and 30/09/06 not fully met. Provide an appropriate 30/09/07 programme of activities in consultation with service users. Timescale of 31/10/06 not met. All of the cases cited in the text 31/07/07 about service users’ finances must be investigated and refunds issued if necessary. The policy about covering the Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 38 costs of food and drink for accompanying staff members must be consistently applied. There must be clear and transparent records of the care home’s charges to service users, any additional charges and the amounts paid by or in respect of each service user. These records must be available for inspection. A wider audit of all service users’ financial records must be undertaken, going back as far as necessary, to check for cases where service users may have covered costs which the home should have covered all or part of, or for situations where errors may have resulted in them being out of pocket. Receipts must always be obtained for all transactions unless it is impossible to do so. Keep the home free from offensive odours. Ensure that chairs are regularly cleaned to avoid any build up of encrusted food. Ensure that food and kitchen hygiene is consistently maintained (see account in text). Ensure that practice in recruitment and selection fully accords with the Care Homes Regulations 2001, notably that all necessary documentation is obtained before the person starts work and is available in the home. All staff must be appropriately supervised. Display the current registration certificate, removing the one naming a former manager. 5 6 7 8 YA24 YA24 YA30 YA34 16 (2) k 23 (2) d 13 (2) 19. Sch. 2 Sch. 4 (6) 30/06/07 30/06/07 31/07/07 31/07/07 9 10 YA36 YA37 18 (2) a Care Standards Act S. 28. 31/07/07 30/06/07 Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 39 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 2 Refer to Standard YA6 YA6 Good Practice Recommendations Consider introducing a bound recording format so that daily records remain in sequence. Take forward plans to introduce more of a ‘total communication’ approach in conjunction with professionals in the community. As part of this explore the potential for introducing ‘intensive interaction’ where service users may benefit from this approach. When updating care plans consider issues around physical contact, as described in the text. Support people to access advocacy services if they wish to or if there is an identified need to do so. Staff should have input about the Mental Capacity Act as soon as possible. Ensure that risk assessments are regularly reviewed. Make suitable arrangements for one person to go swimming again, as referred to in the text. Take forward plans for holidays or (where more appropriate) day trips. Ensure that information about religious/spiritual needs is accurate where this is relevant. Continue to work towards providing people with more choice about what they eat/menus in general, particularly people with greater communication difficulties. Care plans about personal care should reflect service users’ preferences around how and when it is delivered and about the gender of the person providing support. Note the comments made in the text about handover from night to day staff and about recording of observations. Consult with the CLDT whether one person currently without a regular physiotherapy exercise routine would benefit from such a programme, as discussed during the inspection. Ensure that all healthcare appointments are consistently recorded. Aim for one set of healthcare appointment/outcome records in order to avoid confusion. DS0000016360.V340693.R01.S.doc Version 5.2 Page 40 3 4 5 6 7 8 9 10 11 12 YA7 YA7 YA9 YA12 YA12 YA13 YA17 YA18 YA18 YA18 13 YA19 Alexandra House Review and update health action plans. Record weights using the same unit of measurement. Support the two people discussed during the inspection to access dental services, including one person said to be on a waiting list since 2005. Take into account the bullet points made about the handling of medication in the home. Ensure that a copy of the Gloucestershire Adult Protection Unit’s procedures is available in the home. Fit a soap and paper towel dispenser in one person’s ensuite as requested by a relative. Ensure that the drainage problems in the room are resolved so that the en-suite is fully functional. When staff are providing/about to provide some kind of support for a person they should always explain what they are doing or are about to do and why. Note comment made in text about an example of disrespectful interaction. The 13-hour shift arrangement should be reviewed. It is strongly recommended that staff who find this arrangement too tiring should be offered alternative shift patterns with immediate effect. Ensure that all staff working a given shift have a suitable break. Deal assertively with issues around staff sickness levels. Address the issues identified discussed around dynamics in the team(s). Consider arranging further specialist training for staff related to the needs of the people living in the home, such as about tissue viability and autism. Clarify who has been trained to support service users with physiotherapy exercises. Add this information to training records. Ensure that new staff promptly receive necessary paperwork to begin the formal element of their induction, as part of meeting the Common Induction Standards. A more service specific induction which meets the LDAF standards should be made available to staff. Consider ways in which the people living in the home could DS0000016360.V340693.R01.S.doc Version 5.2 Page 41 14 15 16 YA20 YA23 YA24 17 YA32 18 YA33 19 YA33 20 YA35 21 YA39 Alexandra House 22 YA42 be provided with more opportunities to feed back about the care they receive. Carry out another fire drill. Ensure that these are done regularly. Note who was present for each drill. Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 42 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexandra House DS0000016360.V340693.R01.S.doc Version 5.2 Page 43 - 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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