Inspection on 22/04/05 for Alexandra House

This inspection was carried out on 22nd April 2005.

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

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

Other inspections for this house

Alexandra House 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 02/09/05

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 GL1 3DR Lead Inspector Tanya Harding Unannounced 22 April 2005 7.30am and 5th May 2005 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 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 Stationary 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 D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 2 Alexandra Road Gloucester GL1 3DR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01452 418575 Cotswold Care Services Ltd To be appointed Care Home 12 Category(ies) of Learning Disability - Both (12) registration, with number of places Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/02/2005 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 on the first floor, as well as a shower room and two bathrooms. Two of the bedrooms are currently being used for storage. All of the bedrooms have hand-wash basin and on the ground floor there are two spacious lounges, a dining area, an activities room, kitchen, laundry and a small office. The home has two large staircases and a lift from the grond to first floor. The home has a large back garden. Alexandra House is one of three homes and a day centre in Gloucester ownded by Craegmoor Healthcare Ltd. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 7.30 am on a Friday morning, and lasted for about five and a half hours. It was supported by the second inspector, Richard Leech. The acting manager helped with the inspection. There were four staff in the home at the start of the inspection. An additional staff member came in at 8.30 am. All of the service users were in the home and the inspectors met and greeted almost all of them. Many of the service users have complex communication needs and some are unable to communicate verbally. One person spent some time with the inspectors talking and drawing and later showed the inspector around the ground floor of the house. During the inspection a variety of records containing information about service users was examined. There were discussions with the acting manager and three of the staff. The main purpose of the inspection was to check whether the requirements made in the last report with timescales for completion by 30/03/05 have been met. All other requirements from the previous report which were still within timescales are repeated in this report in the Requirements section. The home needs to continue working towards meeting these in a timely fashion. The home was also visited by the pharmacy inspector from the Commission on 5th May 2005. The complete feedback from this visit has been sent to the Registered Provider. The requirements made are also included in this report. The action plan provided by Craegmoor Healthcare in response to pharmacy report of 10th February 2005 could not be fully validated as correct. This was the third visit by the pharmacist inspector and the third manager seen thus there are continuity issues in implementing requirements and recommendations made in previous reports. Craegmoor Healthcare need to provide the resources and management support to permit the continuation of improvements necessary to consistently ensure safe standards of handling and administration of medicines in this home As the Registered Provider, Craegmoor Healthcare Limited has a duty of care to all the service users at Alexandra House. Recent visits and inspections show that Craegmoor has failed to meet many of the National Minimum Standards and have committed several breaches of the Care Homes Regulation 2001. The quality of life for the service users at the home has been very poor and in some cases the welfare of the individuals has been seriously compromised. The Commission has been informed that presence of senior managers in the home has been increased to ensure that there are care plans in place which aim to meet people’s assessed needs, and most importantly that the staff team are fully aware of their role and responsibilities when providing support to service users. The Commission is considering taking formal enforcement action against he Provider. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Commission has received some feedback from a parent that they were unhappy about the way Craegmoor Healthcare had dealt with their complaint. There have been several complaints made about the home within the past few months and a summary of these complaints is included in the previous report. Craegmoor Healthcare needs to ensure that when complaints are made, those charged with investigating issues of concern have the necessary knowledge and skills as well as support from their managers to give the matter the importance it deserves. There are still significant concerns about how the medication is being administered and monitored in the home. The acting manager has made this her priority. Most confidential information is stored securely, but some personal information was not being locked away. At the time of the inspection the service users were not able to access their savings because changes were needed to the signatories. The home must ensure that service users have access to their savings when they want. There are concerns about some parts of the house being very odorous and unsafe for the service users. The home must provide a safe and pleasant environment. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 7 There was still a heavy reliance on agency staff covering shifts. The attitude and practice of some staff is very poor with reports of abusive and neglectful practices towards service users as well as other staff. One member of staff had left in the middle of the inspection after being asked not to swear in front of the residents. The home must take robust steps to improve the performance and attitude of staff. There are several discrepancies in actions Craegmoor said they have completed since the home was last visited and those that actually have been done. This has been pointed out to the Responsible Individual in separate correspondence with request to explain these discrepancies. Craegmoor Healthcare as the registered provider must employ systems to check that actions have been taken as necessary and be satisfied with the outcomes before declaring that a requirement has been met. 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 D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 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 standard(s) 3 The ability of the home to meet the needs of existing service users is compromised and therefore the home cannot provide re-assurances that the needs of any new service users would be met. EVIDENCE: Craegmoor are complying with the Commission for Social Care Inspection not to admit any new service users until the home can demonstrate that it has met certain standards. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 10 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 standard(s) 6,7,9 and10 There are no clear and consistent care plans and risk assessments in place to adequately reflect and meet the needs of service users safely. Sensitive material is mostly stored securely but the location of some documents needs review since it could compromise confidentiality of individual service users. EVIDENCE: Several files were examined on the day of the visit. One file contained an undated assessment and a number of care plans including one about communication. This plan did not provide appropriate information on how the person communicates their wishes and needs. Care plans seen were all dated 10/11/04. There is a system for these to be reviewed monthly but this has not been done. Some care plans did make reference to choice and privacy / dignity. Social Services professionals are carrying out reviews for all Gloucestershire service users. Other placing authorities are also planning reviews for their service users. Once these are done, all care plans and risk assessments will need to be updated. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 11 Manual handling risk assessments to enable service users to access vehicles safely when going out to the community have not been carried out as required previously. Staff who attended the manual handling course said that they should not be taking one specific person out at all but there is no risk assessment is in place to show that the practice used to get the service user into the car is highly dangerous for the staff and the service user. One person who uses a wheelchair did have a risk assessment for using the vehicle safely on their file which referred to the inappropriateness of the current vehicles. Records showing income and expenditure are kept for each person. These showed that weekly allowances are now paid to each individual. The new recording system has only been in place since March 2005 and it was not possible to check whether all of the correct allowances have been received by service users prior to this. The home needs to provide this evidence and compensate people where this may be necessary. All financial records must be clear and easy to audit so that service users can be protected from possible financial abuse. A file containing information about a service user was found in the old office. Several documents containing information about different service users were found in the dining room in an unlocked cupboard. Previously, the inspectors have asked for these to be moved to a more secure place. There have been changes to the way handover meetings are held and the manager is actively reminding staff about not discussing information about service users in front of others. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 12 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 standard(s) 12, 13 and 17 Opportunities to access the community and take part in meaningful activities are poor, with service users spending long unstructured periods of time in the home. EVIDENCE: The home has two vehicles, which are not suitable for the needs of several of the residents. One vehicle can take one person in a wheelchair. Craegmoor Healthcare has promised to find a better vehicle for the home, one that can transport more than one wheelchair at a time, but this has not yet been done. This means that very few service users can go out in the vehicles and this poses restrictions on where people can choose to go. Staff also said that there were no immediate plans to purchase a new vehicle. Attempts were being made to find a suitable car / minibus from within the Organisation. The risk assessments to enable staff to support service users to get in and out of the home’s vehicles safely have not been done. This was subject to an immediate requirement to be completed by 11/02/05. Many service users at Alexandra House have mobility difficulties and require specialist support. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 13 Without the risk assessments staff have no suitable guidance to follow about the safe manual handling techniques and are putting themselves and the service users at significant risk. The acting manager and staff spoken with confirmed that the necessary risk assessments are not in place. Staff have been told that one person in particular must not be assisted into the vehicle in the way the person has been supported to date. From the records seen as well as from discussions and observations in the home it was evident that some progress has been made towards improving activity choices, but this has been very limited to date. The majority of the service users are not engaged in any form of organised or planned activity and opportunities for spontaneous activities, other than walks into town are limited. This means that service users spend most of their days wandering about the home, watching TV or spending time in their bedrooms. The care plans and activity programmes do not provide clear information about people’s aspirations and interests. Two service users went out for a walk into town on the morning of the inspection supported by care staff. Trips out are staff intensive as often one to one staffing is necessary. The day care-coordinator confirmed that another day support worker has been employed and this should make the planning and the organisation of day care easier. Two service users are now attending a Craegmoor owned day centre in the Forest of Dean once a week. Some of the recent trips included a visit to the circus and lunches out. Staff said that some trips are now taking place during weekends. Daily records and care plans were viewed for several service users. There was no evidence of service users being consulted about their interests and ambitions. Steps are being made to make mealtimes more enjoyable for service users. The manager is asking staff to give people a better choice at breakfast, as historically this has been quite rigid. She is also trying to reduce risks from inconsistent supervision at meal times by providing more staff at lunchtime to support service users. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 14 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 standard(s) 18, 19 and 20 Some practices in supporting people with personal care are compromising their dignity, privacy and independence and are not based on preferences of service users. EVIDENCE: Daily records were examined for six service users. This showed that times for getting up and going to bed were quite flexible. Staff said that some service users receive personal care after tea and then come back to the communal areas in their bedclothes. This indicates institutionalised practice and shows lack of activity options in the evenings. Many of the service users are in their 20s and 30s. Lack of information in care plans makes it difficult to establish whether service users are making an informed choice about getting into their bedclothes so early in the evening. Daily records showed that some people are ‘strip washed’ in their bedrooms. It was not clear why service users were not supported to have a bath/ shower as a more ordinary practice other than the limited adaptations in the bathrooms and the dangerous environment in the shower room. A care plan examined for one person about support they require with personal care was incomplete. The urine bottle which went missing some time ago, has not been replaced to date. It has not even been ordered. This is in contradiction to what the inspectors were led to believe. The acting manager Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 15 said that because the service user needs a particular type of a bottle, this cannot be easily obtained, so re-ordering will take time. There is intermittent information about service users’ health care appointments and health monitoring. For one person there were no healthcare records from 2005. The manager said that a member of the CLDT has been coming in to monitor people’s weights. However, there were no records to evidence this and so it was not possible to make an assessment on whether service users were maintaining a healthy and steady weight or whether there were any concerns about weight loss or weight gain, which would need a medical assessment. Many service users have complex physical needs and require regular physiotherapy. This is not taking place. The acting manager said that referrals have been made to the physiotherapist and the occupational therapist to reassess individual needs in this area and to issue better guidance for staff. The manager also hopes to provide a soft floor area in one of the lounges for people to spend time out of their wheelchairs. Referrals have also been made to the Community Learning Disabilities Team for support with behaviour management. The manager felt that some of the unsociable behaviours displayed by the service users are related to poor and inappropriate responses by staff. There have been ongoing problems with medication in the home and the Commission has been informed of these. The manager has stopped all but three staff from administering medication because of the worry that more mistakes may be made. This has created problems with rotas, as the manager has been trying to cover each shift with at least one person who can give out medication. The situation did become quite unacceptable and the Commission has since learnt that agency nurses are now employed to give medication out at night. There are plans to train other care staff in administering medication competently. They will be put through an accredited training course, but this could take several months. The Commission has been informed that nursing staff will continue to be employed to cover nights until the care staff have achieved the necessary level of competency. The acting manager has re-established links with the local GP and has made arrangements for a medication review for the service users in the near future. The manager felt that one person was enjoying a better quality of life since their medication has been reviewed. The Pharmacy Inspector from the Commission has followed up the requirements made about improving medication systems after the last inspection. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 16 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 standard(s) 22 and 23 Arrangements for protecting service users are not satisfactory, putting them at risk of harm and abuse. EVIDENCE: There is no evidence of any consultation with the service users and no evidence of individuals being aware of their rights to raise concerns and complain. An example was seen in incident reports of a service user requesting to lie down on the sofa, and staff member telling the service user that they should not do this. The service user got very upset about this and displayed aggression towards the staff member. The outcome was that the service user remained sitting in their wheelchair. This incident demonstrates a disregard for service user choice and of power staff have over the service users in the home. In this incident the service user was able to communicate their wishes verbally. Many of the service users in the home are unable to communicate their views in this way. Another incident described how a staff member made a service user say ‘sorry’ for their behaviour. The incident described that the person was struggling and hitting out whilst receiving personal care, but there was no reference as to whether the person was doing this because they were frightened or in pain for example. This demonstrates lack of awareness by staff as to the triggers for aggressive behaviour and lack of appropriate responses to such behaviours. The home has been receiving regular visits from social services professionals, who have been carrying out re-assessments of people’s needs. These assessments show that many of the assessed needs are not being met or addressed in any way. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 17 Discussions with outside professionals provided evidence of other incidents where service user’s choices are being ignored / disregarded by staff. Several issues have come to light since the inspection which evidence abusive and neglectful practices in the home. The acting manager has shared her concerns about staff attitudes and their reluctance to change poor and outdated practices. There are reports of bullying amongst staff and evidence of collusion over poor practice. This makes it difficult for the team to progress and compounds poor value base and practice. Some staff feel exploited and some are going along with poor/ dangerous practices because they are being picked on by others and whistle blowing has not been effective. There is lack of training in key areas such as Protection of Vulnerable Adults, Communication, Recognising and Reporting of Abuse, Service User Empowerment. This means that staff do not have the knowledge or skills to assess their own practice. A financial audit has been carried out in the home and some information about the findings has been forwarded to the Commission. However, some of the questions about service users’ expenditure and whether all correct allowances have been received by the individuals prior to the last inspection remain unanswered. This includes DLA mobility entitlements and the weekly personal allowances. A recording for one person suggested that they had fallen out of bed on 21/04/05. The person was quite ill on 19th and 20th April and a GP was called to them on the 20th April 2005. The fall was not clearly described in the record, but it was clear that the person’s bed was raised and would not go down, as it was not functioning properly. The inspectors saw the bed. This was stuck in the elevated position and has been like this for about a week. The inspectors were concerned that if the person did fall from this height that they may have required a medical examination to check if they were all right. The manager said she was not made aware of the fall and agreed to look into the incident. There were no records suggesting that medical help was sought for the service user. The person has profound physical needs and requires staff support with mobility. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 18 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 standard(s) 24, 27, 29, 30 Parts of the environment remain unsafe and inappropriate for the needs of the service users, placing them and staff at risk of injury. EVIDENCE: The entrance area in the home now presents as more welcoming and the ground floor was tidy and clean on the day of the inspection. Some of the requirements made in the last report have been met. There are subsidence problems to the front elevation of the house and plans are being put in place to carry out the necessary building work. One person has been moved to an alternative room due to subsidence affecting problems in their room. Two of the bedrooms had strong smell of urine. One room (room 10) was due to be redecorated and the manager said she was looking at changing the carpet. There is a lift to the first floor, which has not been reliable in the past. The lift was working on the day of the visit and one service user was observed using this independently. When the lift breaks down, the service users who cannot manage the stairs are effectively trapped on the first floor. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 19 The shower room was very odorous. Staff explained the problems they have when supporting service users to have a shower. These include slippery floors, which are very difficult to clean and keep dry; the shower itself, is positioned so that staff have to lean over the sides of the cubicle to help people wash. This is very awkward and potentially could cause an injury. There is little room to manoeuvre safely with wheelchairs and walking aids and there are no other aids or adaptations in this room. The room had a bolt on the door, which staff explained they used to stop service users from entering. This is because service users had slipped on the wet floor in the past, and so were seen to be at risk. The shower room is used daily by at least seven of the residents and this makes the likelihood of injury to staff or to service users very high. One of the bathrooms on the first floor does not have any suitable adaptations at all to enable people with mobility problems to have a bath here. As a result, this spacious room is hardly used. This means that there is just one bath which can be used in the home. However, this is very dark and limited on space. There are no changing facilities here and people who use the bathroom would have to undress in their rooms. The requirement to provide the necessary adaptations has been outstanding since August 2004. The inspectors asked for precautions to be taken about the unlocked boiler cupboard in room 8. As an immediate action, the manager locked this room. The window in Room 2 did not shut properly. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33,34,35 Many staff supporting the service users do not have the skills, values, aptitudes and knowledge to meet their needs in a professional and respectful manner. There is poor continuity of care and an ineffective staff team. There has been lack of training opportunities which has resulted in an under skilled staff team. Staff have not been receiving regular supervision and this, over a period of time, has lead to the development of an institutionalised culture amongst the staff which is abusive. The procedures for recruiting staff are still not sufficiently robust and do not provide the safeguards to offer protection to service users. EVIDENCE: Upon arrival to the home the inspectors observed one staff member reading a newspaper when the another three staff on duty were engaged in carrying out care and support tasks. The numbers of staff have on the whole been maintained at five per shift. This has only been possible by covering many of the hours with agency staff. This means that service users are often supported by people who do not know them well and may not be aware of their assessed needs. Records, observations and discussions with staff, manager and outside professionals provided examples of poor attitudes amongst staff towards their work and lack of commitment to do things well. Some examples showed that Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 21 service users were not treated with respect and that they were being denied choice. There was also evidence that staff lacked communication skills and did not know how to respond to people who were being aggressive. The quality of daily records was quite poor and training needs in this area were discussed with the acting manager. One record said that the service user was ‘having a cheeky moment’. This was a descriptive and not a factual statement. Such records are unhelpful in that they do not define what the person was doing and why this was significant. The manager said that she is actively picking up staff on poor practice, such as when they are openly talking in front of others about confidential and private issues. Disciplinary action is being taken against staff when misconduct has been identified. New staff have been recruited but the majority have not stared work as the necessary employment checks have not yet been completed. Checks such as employment history, references, Criminal Record Disclosures and a check against the Protection of Vulnerable Adults register need to be obtained for all staff before they start work in the home. These are essential steps in protecting vulnerable service users from staff who may be unsuitable. The necessary records have not yet been obtained for all current staff as required in the last report and the file for one of the newer staff members who is working in the home has not been forwarded to the home from the personnel department. This made it impossible to determine whether this person posed a risk to the service users. The acting manager has implemented a risk assessment which states that the person cannot work alone. The last inspection showed that staff training has been irregular and very limited. To date some training has been provided for staff in manual handling. There is CPI (Crisis Prevention) training arranged for up to 12 staff on the 19th and 20th May 2005. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 and 43 There has been lack of effective leadership and accountability in the home over the past few months and this has resulted in development of practices which do not promote and safeguard the health, safety and welfare of the service users. EVIDENCE: Since the last inspection a new acting manager has been working in the home. The manager has several years of management experience and has worked for the Organisation for some time now. She was clear about the sizable task of necessary improvements and provided an additional overview of the many failings which are identified in this and in the previous reports. The Commission has concerns about the level of support needed for the home to begin to address those failings. Having an experienced manager in place is a step in the right direction, however, many of the concerns linked to the staff team cannot be changed or improved immediately and will continue to cause concern about the care provided to the service users. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 23 The manager has demonstrated a sound commitment to promoting good practice and has already challenged several staff about their attitudes. Since the inspection the Commission has been informed that disciplinary action is being taken against some staff as a way of addressing practice concerns. Gloucestershire Social services have instructed Craegmoor Health Care as the Registered Provider to arrange and hold a meeting with the parents / carers of the service users at Alexandra House. This will be an opportunity for people to share their views of how the home is being run and to discuss any concerns and worries they may have about the care of their relative. Several relatives have already voiced their dissatisfaction with the home and some made formal complaints to the Commission and to Social Services. Information about recent complaints is included in the last inspection report. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 24 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 1 x x Standard No 22 23 ENVIRONMENT Score 1 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 1 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x 1 x 1 2 Standard No 11 12 13 14 15 16 17 x 1 1 x x x 2 Standard No 31 32 33 34 35 36 Score x 1 1 2 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alexandra House Score 1 2 1 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 1 2 D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 25 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 3 Regulation Requirement Timescale for action 30/04/05 2. 5 12 (1) a. Provide specialist communication 18 (1) (c). training for staff in accordance with service users’ needs. Include reference to Total Communication principles and methods (Timescale of 30/09/04 not met). 5 (1) b & · Terms and conditions must c. 12 (1) be supplied to service users as a.17 (2). part of the Service Users Guide. Sch. 4 (8) These must be fully up to date & (9) and accurate (Timescale of 31/08/04 not met). · These must include clarification of the arrangements for service users to contribute towards the cost of transport in the home · There must be clear documentation available in the home of how much each person has contributed towards transport and what that money has been spent on. (Timescale of 31/08/04 not met). Clarify to service users, their representatives and the Commission whether service users’ have some accumulated savings (from DLA mobility payments) held centrally in a D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc 30/04/05 Alexandra House Version 1.30 Page 26 Craegmoor operated account. 3. 6 12 (1) a. 14 (2). 15(1)(2) · Keep service users’ needs assessments under review. Revise/update as necessary. · Care plans must clearly state how each service users’ assessed needs are to be met (including personal care requirements and the management of challenging behaviour). Ensure that care plans are followed and form the basis of practice. · Review and update all physical intervention protocols, involving a suitably qualified clinician. Base protocols upon the Department of Health guidance on restrictive physical intervention and relevant Care Homes Regulations and National Minimum Standards. (Timescale of 31/08/04 not met). · As part of above, include consideration of use of physical intervention on the staircase and the use of slide sheets to move service users in response to aggression and/or distress (Timescale of 31/12/04 not met). Provide training in physical intervention for all staff by a BILD accredited training provider. (Timescale of 30/09/04 not met). Keep a record of any limitations agreed with a service user as to their freedom of choice, liberty of movement and power to make decisions. (Timescale of 31/08/04 not met). Risk assessments must be clear, reviewed regularly and linked to care plans. (Timescale of 31/08/04 not met). 30/06/05 4. 6 12 (1) a. 13 (5), (6), (7) & (8). 14. 15. 18 (1) c (i) 30/04/05 5. 7 17 (1) a. Sch. 3.3 q 30/04/05 6. 9 12 (1) a. 13 (4). 14 (2). 15. 30/04/05 Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 27 7. 8. 9. 9 10 12 13 (4) 12 (4) a. 17 (1) b 12 (1) a. & (4) a. 13 (4) & (5) 10. 12 12 (1) a. 16 (2) m 11. 12 12 (1) a. 13 (2) & (3). 14 (2). 15 (1) & (2). 16 (2) m &n 12. 18 12 (4) a 13. 18 12 (1) a & b Complete a risk/hazard analysis of the building (Timescale of 31/08/04 not met). All confidential material must be kept securely in the care home. Timescale of 28/02/05 not met. Devise and implement appropriate procedures for supporting each service user to get in and out of the home’s vehicles. Ensure that procedures are as safe as possible, are risk assessed as necessary, that service users’ dignity is not compromised and that basic moving and handling guidelines are followed. Seek advice as required. (Subject of an immediate requirement issued 02/02/05), Timescale of 11/02/05 not met. Ensure that more than one wheelchair user at a time can be transported in the home’s vehicle(s) (Timescale of 30/11/04 not met). Service users’ needs in respect of activity and occupation (including social and recreational interests) must be fully reassessed, in consultation with them and their representatives as appropriate. Care plans and provision must reflect these assessed needs. Suitable arrangements must be made for service users to engage in local, social and community activities. This includes provision of appropriate activities in the evenings. Service users’ privacy and dignity must be fully respected when staff provide personal care support. Timescale of 15/02/05 not met. One service user’s lost urine bottle must be replaced with an 30/04/05 30/06/05 30/06/05 30/04/05 30/04/05 30/06/05 30/06/05 Page 28 Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 14. 18 12 (1) a & b. 13 (4), (5) & (6). 14 (1) a. 15. 18 (1) a&c 15. 19 12 (1) a & b. 13 (1) b 16. 19 12 (1) a & b. 17. 19 17 (1) (a). Sch. 3 (3) (m) 18. 20 18(1) appropriate bottle, as discussed during inspection. (Subject of an immediate requirement issued 02/02/05). Timescale of 11/02/05 not met · There must be a review of all moving and handling procedures in the home to include the ways in which each service user is supported to move/mobilise. Specialist input must be sought as necessary to ensure that personal support with mobility and moving & handling procedures are safe and appropriate. Document in care plans. Provide training for staff as necessary. Include assessment and protocols for use of slide sheets on an individual basis (Timescale of 15/04/05 not met) Appropriate provision must be made for wheelchair users living in the home to be weighed at suitable intervals. Records must be kept of weights and medical advice sought if necessary (Timescale of 31/10/04 not met). Timescale of 28/02/05 not met. Ensure that service users’ physiotherapy programmes take place as recommended by external professionals. Timescale of 28/02/05 not met. An accurate and complete record of service users health appointments and needs must be maintained (Timescale of 30/08/04 not met). Timescale of 28/02/05 not met All staff designated to handle medication to commence accredited training and documented assessment of competence in safe handling of medicines. (Previous timescale 30/06/05 30/06/05 30/06/05 15/06/05 17th June 2005 Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 29 of 15/03/05 not met) 19. 20 13(2) Specific local medication procedures to be written. All staff to be made aware of this and monitored in their understanding and adherence to procedures. Medicine administration procedures to be reviewed to ensure they comply with accepted safe practice contained in the guidelines from the Royal Pharmaceutical Society of Great Britain. (Previous timescale of 28/02/05 not met) Full records to be kept for receipt of all medicines. (Previous timescale of 28/02/05 not met) All containers of medicines to be dated when first opened for use to allow audits to demonstrate correct medicine administration and stock levels to be regularly conducted. Administration of all prescribed medicines to be fully documented on the MAR charts Where administration of medication involves crushing tablets this to be documented in agreed protocols. (Previous timescale of 28/02/05 not met) Storage of external medicines to be reviewed to comply with the guidelines from the Royal Pharmaceutical Society of Great Britain Forward to CSCI complete breakdown of costs for each service user from holiday to Tenerife in October 2004, with evidence in the form of printed receipts. (Subject of an immediate requirement issued 02/02/05) Timescale of 11/02/05 not met. Suitable aids and adaptations 30th June 2005 20. 20 13(2) 17th June 2005 21. 22. 20 20 13(2) 13(2) 17th June 2005 17th June 2005 23. 24. 20 20 17(1) 17(1) 17th June 2005 17th June 2005 25. 20 13(2) 17th June 2005 26. 23 12 (1) a. 17 (2). Sch. 4 (9) 15/06/05 27. 27 23 (2) n 30/04/05 Page 30 Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 28. 28 23 (2) b & d 29. 30 30. 30 12 (1) a. 13(3). 16 (2) k. 23 (2) d. 13 (3) &(4), 16 (2) j, 23 (5). 31. 32 12 (4) a. 18 (1) a & (c) i 32. 34 13 (6). 19 (1 33. 35 12 (1) a & b. 13 (2), (3), (4), (5) & (6). 17 (2). 18 (1) c (i). 23 (4) d. must be installed in the new bathroom in order to make it as accessible for service users as possible. Consult with appropriate professionals for advice, such as an Occupational Therapist (Timescale of 31/10/04 not met). Address the subsidence affecting the front lounge). Redecorate this room once completed (Timescale of 31/10/04 not met). All parts of the home must be kept clean and free from offensive odours. (Timescale of 28/02/05 not met) Review hygiene measures in the kitchen, in consultation with an Environmental Health Officer as appropriate. Include consideration of additional fly screen on side window, UV flykilling device, provision of suitable protective clothing for staff entering the kitchen and any other measures assessed as appropriate. Staff are not to eat in the kitchen. Staff must receive training around attitudes, values, privacy and dignity. (LDAF training (induction, foundation and specialist units) may be a way of addressing this). Undertake CRB and PoVA checks for all longer-serving staff identified as not yet having undertaken these checks. (Timescale of 28/02/05 not met). Staff must receive training appropriate to the work they perform, including being up to date with mandatory training. There must be a record of all training undertaken. 30/06/05 15/06/05 31/05/05 30/04/05 15/06/05 31/05/05 Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 31 34. 35. 36 42 Sch. 4 (6) g 18 (2) 13 (4) 36. 23 37 37. 22 22 38. 23 13(6) 39. 27 13(4)(6) 40. 27 23 41. 24 23 Staff must receive appropriate supervision. (Timescale of 31/03/05 not met). If, following risk assessment, it has been decided that the laundry needs to be kept locked when unattended then this must be done consistently. (Timescale of 28/02/05 not met). Investigate the incident which took place on 21/04/05 and provide the necessary notification to the Commission. Inform all service users about their right to raise concerns and to complain in the way which is meaningful to each person. Provide evidence of this in individual files along with the communication guidance for each person showing how they express their dissatisfaction or upset. Staff must receive training in protection of vulnerable adults, recognising and reporting of abuse, promoting service user empowerment and in managing aggression Carry out a risk assessment of the shower room, detailing all of the existing hazards. Make alterations to the walk-in shower facility to remove these hazards and to provide a safe and pleasant environment in this room. Improve facilities and adaptations in the bathroom with accessible bath to make this more suitable to the needs of the service users. Provide suitable changing facilities in the bathrooms. Repair the window in room 2 so that it closes properly 30/06/05 15/06/05 30/06/05 31/07/05 31/07/05 31/07/05 31/07/05 30/06/05 Page 32 Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 42. 34 17 Records about staff employed in the home must be kept and available for inspection. 30/06/05 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 6 Good Practice Recommendations · Promote the staff team’s awareness of, and involvement in, the care planning process. · Review the standard of record keeping in the home. Cross reference daily records to care plans. Ensure that all pertinent information is recorded (see example in text of outside professional commenting on record keeping in respect of behaviour monitoring). · Audit care planning files. Archive outdated material. Organise files and documentation in a clear, consistent way. Assess the quality of care plan reviews, to ensure that staff are undertaking this thoroughly, and are updating care plans when necessary. · Review the day-care service provided in the home, and the use of day-care room, to ensure that provision corresponds to service users’ needs and interests. This should include whether the day-care coordinator requires any additional training and support, and a review of the job/role description. There should either be separate activities records kept by the day care coordinator, or entries relating to activities in daily records should be fuller (based upon each person’s needs assessments and care plans in respect of activities). Ensure that there are enough drivers to meet service users’ needs in terms of transport provision. There should be to be clear, consistent communication with family members as is appropriate for each service user’s circumstances. The team should review how this is managed. Service user’s consent to medication to be recorded in the individual plan. The controlled drug cupboard to be secured to the wall with two rag / rawl bolts. · Ensure that all staff are fully aware of the complaints procedure and that they are confident about when it would D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 33 2. 12 3. 4. 12 15 5. 6. 7. 20 20 22 Alexandra House 8. 9. 23 23 10. 23 11. 34 12. 42 be appropriate to invite family members to go through this procedure should they wish to. Review and update the complaints procedure. Remind all staff of the whistle blowing policy and the protection in law that they receive for concerns raised in good faith. Financial arrangements with the appointee who receives one service user’s benefits should be discussed and agreed in order that there is complete clarity. This would include invoices and receipts where appropriate. The inspectors suggested that the person’s social worker could coordinate this. Discuss the possibility of opening of a bank account for one service user with their family/representatives as described in the text. Depending on outcome take steps to move this forward. The provider should review policies and procedures regarding the recruitment of staff from abroad, including deciding upon, and adhering to, essential pre-requisites for the posts to be filled. Managers should have more involvement in the selection and deployment of these workers in so far as it affects the home they run. The provider should review procedures for accommodation, induction and orientation of staff recruited from abroad. Review the use of the maintenance log book to ensure that it is an effective working document, and that it provides clear evidence of work planned and completed. Alexandra House D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 34 Commission for Social Care Inspection 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 D51_D03_S16360_AlexandraHse_V224885_220405_Stage4_U.doc Version 1.30 Page 35 - 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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