Inspection on 26/09/06 for Alexandra House

This inspection was carried out on 26th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexandra House 09/10/08

Alexandra House 17/04/08

Alexandra House 28/12/05

Alexandra House 14/06/05

Alexandra House 15/12/04

Alexandra House 22/07/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Alexandra House Alexandra House 31 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JL Lead Inspector Deavanand Ramdas Unannounced Inspection 3rd October 2006 10:00 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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 DS0000013549.V312339.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 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) Alexandra House 31 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JL 01883 380739 Mrs Myrna Noorbaccus Mr Mike Noorbaccus Mrs Myrna Noorbaccus Mr Mike Noorbaccus Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed FIVE (5). The age/age range of the persons to be accommodated will be: 3 PEOPLE UP TO 64 YEARS & 2 OVER 65 15th December 2004 Date of last inspection Brief Description of the Service: Alexandra Home is registered with the CSCI (Commission for Social Care Inspection) to provide accommodation and care to five service users who have a learning disability. The property is located in a residential area in Oxted in Surrey and close to public amenities. Accommodation is on two floors accessed by stairs and comprises of a kitchen, dining room, lounge, laundry area, bathrooms, toilets, one shared bedroom with en-suite facilities and four single bedrooms. The home has a front garden and a rear garden which is secure and easily accessible. Private parking is available. The range of fees charged by the home is £700 - £1600 per week. The registered manager is Myrna Noorbaccus. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes key inspection by the CSCI (Commission for Social Care Inspection) and carried out by one inspector over a period of six hours. The site visit commenced at 10:00 hours and finished at 16:00 hours. A partial tour of the premises took place, staff and service users were spoken to, and documents and records were examined. The inspector noted some service users living at the home have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the manager, staff and service users for their contribution to the inspection. What the service does well: The home has an experienced registered manager who has the RMA (Registered Manager Award) and a professional nursing qualification to ensure the home is run by a person fit to be in charge of the home. Further evidence indicated the manager provided leadership and direction to the staff team and during discussions a member of staff stated ‘‘management is very good, helpful and always supportive’’. The home is committed to staff training and development reflected in an accolade from Skills for Care and IIP (Investor in People Award). Further evidence indicated the home exceeded Standard 28 of the NMS (National Minimum Standards) with over fifty percent of staff having NVQ (National Vocational Qualification) training to ensure service users are in safe hands at all times. During discussions a member of staff stated ‘‘I am happy with training opportunities’’. Meals at the home are good and offer variety and choice. Further evidence indicated menu plans have input from a dietician to ensure it is adequate to meet the nutritional needs of service users. During discussions a service user stated ‘‘I like steak and kidney pie, yes I do and trifle’’ and a member of staff remarked ‘‘meals are home made and freshly cooked’’. Activities at the home are organised and reflect the choice of service users. A review of records indicated service users participated in preferred activities and during discussions a service user commented ‘‘I went to Bluebell Railway, I went on the train there, yes I did’’. Further evidence indicated staff supported service users on summer vacation in Wales and during discussions a member of staff stated ‘‘service users are well looked after and have a lot of activities to do’’. The home values equality and diversity and staff working at the home have training in diversity awareness included in the NVQ (National Vocational Qualification) training. On the day of the inspection staff supported service users in the kitchen to prepare a lunch of home made chicken pie with freshly cooked vegetables to promote independence and the manager encourages service users to participate in community life by paying for visits to local pubs and restaurants. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 DS0000013549.V312339.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service guide needs strengthening to ensure prospective service users and their relatives have up to date information on which to make decisions about admission to the home. The arrangements for the assessment of needs are good ensuring service users’ needs are assessed before admission to the home. EVIDENCE: The home has a statement of purpose and service user guide which is nicely presented, written in plain English and accessible for information. Following discussions with the manager a requirement has been made for information Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 9 about the range of fees charged by the home to be included in the service user guide to ensure prospective service users have up to date information on which to make decisions about admission to the home. The manager stated prospective service users are admitted to the home following an assessment of needs and the inspector noted assessment of needs reflected personal care, health needs and social support. Further evidence indicated a service user admitted to the home had an assessment by the manager and a community care assessment had been completed to ensure service users’ needs were fully assessed and identified before admission to the home. The manager stated the home did not offer intermediate care and this standard was not assessed. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning at the home needs strengthening to promote the personal, health and social care needs of service users. The systems for accessing healthcare are good ensuring service users healthcare needs are assessed and met. The arrangements for privacy and dignity are good ensuring service users privacy is upheld. The management of medications at the home is good and promote health. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 11 EVIDENCE: The manager stated service users have care plans which are drawn up following an assessment of needs and the inspector noted the home had person centred plans which sets out in detail actions to be taken with regards to personal, social and health care needs. A review of records indicated care plans, risk assessments and a treatment plan for epilepsy were in need of updating to promote the health of service users. During discussions the deputy manager stated ‘‘service users are well looked after and have a lot of activities to do’’. The manager stated service users have access to healthcare professionals to meet their needs and the inspector noted service users are registered with a local GP and the home have input from a dietician and contact with a physiotherapist and district nurses as is necessary. The deputy manager stated the home had a policy on medications and the inspector noted the home had a service level agreement with a local chemist. Medication record sheets had a recent photograph of service users, were dated and signed by staff and the home kept a record of medications received and disposed of by the home to prevent mishandling of medications and promote health. A review of records confirmed staff have accredited training in medications and observations confirmed medications were adequately and appropriately stored in the home. The manager stated the home had a policy on privacy and dignity and observations confirmed staff addressed service users by their preferred names and the deputy manager knocking on doors before entering toilets, bathrooms to ensure service users right to privacy is upheld. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for activities are good ensuring service users social and recreational interests are catered for by the home. The systems for family contact are good ensuring service users maintain links with family and friends as they would wish. Opportunities for exercising choice are good ensuring service users are helped to exercise autonomy over their lives. Meals at the home are good and offer variety and choice. EVIDENCE: Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 13 The manager stated the home had a daily activity programme for service users and the inspector noted service users have the opportunity to participate in leisure and social activities recorded in service users daily notes. The daily activity programme indicated access to a local adult education college and an activities centre for computer classes. Observations confirmed one service user listening to music which was his preferred activity and moving freely in the home. A review of records indicated staff supported a service user to travel by train on a regular basis to satisfy his recreational interest and the home had contact with a local vicar to meet the religious needs of service users. During discussions a service user commented ‘‘I went to the Bluebell Railway, I went on a train there, I did’’. The manager stated service users have contact with family and friends and the home had a flexible visitor’s policy to promote links with relatives. A review of records indicated a relative visited the home on the 03/09/06 to maintain family contact and the manager stated the service user enjoyed the visit and was happy and smiling. The deputy manager commented service users are helped to exercise choice and are entitled to bring personal possessions to the home. A review of records indicated service users have access to advocates to promote choice and the manager acted as appointee to safeguard the financial affairs of service users. The manager stated the home had written menu plans which had input from a dietician to ensure it is adequate to meet the nutritional needs of service users. On the day of the inspection observations confirmed service users prepared a lunch of home made chicken pie with fresh vegetables including boiled potatoes, carrots and cabbage and dessert was trifle. Mealtime was relaxed and unhurried and meals were nicely presented. During discussions a service user stated ‘‘I like steak and kidney pie, yes I do’ and the manager remarked service user went for meals to a local restaurant on a weekly basis, paid for by the company, to promote participation in community life. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process is good with complaints information available to staff, service users and relatives. The arrangements for protection are good and safeguard the welfare of service users. EVIDENCE: The manager stated the home had a complaints policy which is available in the policies and procedures file and the inspector noted complaints information in the statement of purpose. The manager remarked the home had a complaints folder which was sampled and no complaints recorded. A review of records indicated no complaints about the home since the last inspection by the CSCI (Commission for Social Care Inspection). During discussions a staff stated she was ‘‘aware of the complaints procedure’’ and observations confirmed service users were happy, relaxed and moved freely in the home. The home had a policy on safeguarding adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. The manager commented staff have training in safeguarding adults reflected in staff training Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 15 records and during discussions the deputy manager remarked ‘‘abuse is taken seriously, very much and will be reported’’. A review of records indicated staff have training in challenging behaviour to ensure verbal and physical aggression is understood and dealt with appropriately by staff to safeguard the welfare of service users. Further evidence indicated no safeguarding adult matters were recorded about the home. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the premises are good ensuring service users live in a safe and comfortable environment. The arrangements for hygiene are adequate ensuring the home is clean and hygienic for service users. EVIDENCE: Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 17 The manager stated the home had plans to improve the environment by adding a conservatory to the home to provide more space for the enjoyment of service users and a shared bedroom will be converted into two single bedrooms to provide privacy and dignity. The driveway will be improved and maintenance to the outside of the property will be undertaken to promote safety. Following discussions with the manager a requirement has been made for the home to do a written plan outlining future developments and a copy sent to the CSCI(Commission for Social Care Inspection) for information. On the day of the inspection the home was clean, well presented and free from mal odour and furniture and fittings were adequate. The standard of décor throughout the home was satisfactory. The home operated restricted access to the front entrance to promote the safety of service users and the gardens were well maintained and accessible to service users. The manager stated the home had a policy on infection control and staff have infection control training. Observations confirmed the home had gloves, aprons and staff washed their hands regularly to prevent the spread of infection. Laundry facilities were adequate with a washing machine and dryer and a review of records indicated laundry equipment was regularly maintained to promote safety. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring there are sufficient numbers of staff to meet the needs of service users. NVQ (national vocational qualification) training for staff is excellent ensuring service users are in safe hands at all times. The systems for recruitment need strengthening to protect service users from harm Induction training is good ensuring staff are trained and competent to do their jobs. EVIDENCE: Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 19 On the day of the inspection the deputy manager and a support worker was on duty with the manager providing additional support and four service users were in the home. The manager commented staff have the skills and experience necessary to support service users in the home. Observations confirmed staff were good listeners, communicators and were approachable and comfortable with service users. A review of records indicated the home had introduced a waking night staff to improve supervision and support on night duty and the manager remarked staffing levels will be increased to meet the changing needs of a service user. Staff training records indicated staff have completed LDAF (learning disability award framework) training and NVQ (National Vocational Qualification) training to give them the knowledge and skills necessary to work with service users in the home. The inspector noted the home exceeded Standard 28 of the NMS (National Minimum Standards) with over fifty percent of staff with NVQ training to ensure service users are in safe hands at all times. The manager stated the home had a policy on staff recruitment and staff are vetted before being employed by the home. The inspector sampled staff recruitment files and noted employees have completed application forms, two references, statement of terms and conditions, job descriptions and CRB (criminal record disclosure) information. Following discussions with the manager a requirement has been made for staff to be given copies of the codes of conduct and practice set by the GSCC (General Social Care Council) to safeguard the welfare of service users, recruitment files to have a recent photograph of the employee and application forms to include a full employment history of prospective employees to protect service users from harm. The manager remarked the home has an induction policy and staff have induction training. The inspector sampled staff induction training records and noted the home had a structured induction programme. Induction records were dated and signed by the employee, supervisor and training was linked to service users’ needs. During discussions a member of staff stated ‘‘I am happy with training opportunities’’. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35&38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home are good ensuring service users live in a home which is run and managed by a person fit to be in charge of the home. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 21 The systems for quality assurance need strengthening to ensure the home is run in the best interests of service users. Policies and procedures for managing service users’ money are good ensuring the financial interests of service users are safeguarded. The arrangements for health and safety are good and promote the welfare of staff and service users. EVIDENCE: The home has a registered manager who provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘management is very good, helpful and always supportive’’. The inspector noted the home had a management structure and there are clear lines of accountability in the home. Further evidence indicated the manager has the RMA (Registered Manager Award) qualification and a professional nursing qualification to ensure the home is run by a person fit to be in charge of the home. The manager remarked the home had a policy on quality assurance and the home had discussions with staff, service users and families to obtain feedback about the home. The home has met the previous requirements made by the CSCI (Commission for Social Care Inspection) and policies and procedures are maintained up to date to promote good quality assurance. Following discussions with the manager a requirement has been made for the home to conduct an annual survey involving relatives, service users and other stakeholders to ensure the home is run in the best interest of service users. The manager stated the home had a policy on service users money which was in the policies and procedures file and the home provided facilities for the safe-keeping of service users money. The inspector noted the home maintained a record of all transactions involving service users money which sampled with no discrepancies. The home has a health and safety policy and staff have training in health and safety, first aid, food hygiene, infection control, moving and handling and other appropriate and relevant training. The home has a policy on COSHH (control of substances hazardous to health) and observations confirmed products were stored in a locked cupboard and the home had data sheets to promote the safety of staff and service users. The home had a legionella bacteria test, checks to fire equipment and a gas safety certificate to safeguard the welfare of service users. Further evidence indicated the kitchen was clean, hygienic and fridge and freezer temperatures were within normal limits to promote food safety. Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 3 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 3 Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No. 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 OP1 Regulation 5(1)(b) Requirement Timescale for action 01/12/06 2. OP7 3. OP8 4. OP19 5. OP29 The registered person must ensure information about the range of fees charged by the home is included in the service user guide to ensure prospective service users have up to date information on which to make decisions about admission to the home. 15(2)(b) The registered person must ensure care plans and risk assessments are reviewed regularly to reflect the changing needs of service users and promote health. 13(1)(b) The registered person must ensure the treatment plan of a service user with epilepsy is reviewed and updated to promote health. 23(2)(b)(h) The registered person must produce a written plan outlining the proposed developments of the home and a copy sent to the CSCI (Commission for Social Care Inspection) to safeguard the interest and welfare of service users. 7,9 The registered person must Schedule 4 ensure recruitment files contain DS0000013549.V312339.R01.S.doc 01/11/06 10/10/06 01/11/06 01/12/06 Page 24 Alexandra House Version 5.2 6. OP29 7. OP33 a recent photograph of the employee and application forms are amended to include a full employment history of prospective new employees to protect service users from harm. 12(5)(a)(b) The registered person must 01/12/06 ensure employees have a copy of the GSCC (General Social Care) code of practice to protect service users from harm or abuse. 24(1)(a)(b) The registered person must 20/01/07 consult service users, relatives and other stakeholders to obtain feedback about the home to ensure it is run in the best interest of service users. 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 *RCN Good Practice Recommendations No recommendations were made at this inspection Alexandra House DS0000013549.V312339.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013549.V312339.R01.S.doc Version 5.2 Page 26 - 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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