Inspection on 28/12/05 for Alexandra House

This inspection was carried out on 28th December 2005.

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

The inspector 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 26/09/06

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 ADULTS 18-65 Alexandra House Alexandra House 31 Pollards Oak Road Hurst Green Oxted Surrey RH8 0JL Lead Inspector Deavanand Ramdas Announced Inspection 28th December 2005 10:00 Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V256441.R01.S.doc Version 5.0 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 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.V256441.R01.S.doc Version 5.0 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 14th June 2005 Date of last inspection Brief Description of the Service: Alexandra Home is a care home for six people with a learning disability and is located in a residential area in Oxted, Surrey. The home offers accommodation on two floors and has a kitchen, dining room, lounge, laundry room, bathrooms and toilets. The home has four single bedrooms and one shared bedroom with en-suite facilities. The home has a front garden and a rear garden which is secure and easily accessible. Private parking is available. The property is close to local amenities and the home has its own transport for community activities. The registered manager is Myrna Noorbaccus. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of six hours. A full tour of the premises was carried out, staff and service users were spoken to, care records and documents were inspected. The inspector noted some service users had communication difficulties and judgements were made based on their mood and behaviour during the inspection. The inspector would like to thank the manager, deputy manager, staff and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 6 The home must ensure service users care plans are developed to reflect person centred planning and such care plans are reviewed at least every six months and changes recorded and actioned. The home must provide a screen in the shared bedroom to ensure the privacy and dignity of service users and a small fridge to ensure medicines are adequately and appropriately stored. The home must have available sample signatures of staff who administer medications for information and contracts must be offered to service users to ensure their tenancy rights are safeguarded and protected. 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.V256441.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4&5 The homes statement of purpose and service user guides are satisfactory providing service users and prospective service users with details of the services the home provides enabling an informed choice to be made about admission to the home. The homes admission policy is good ensuring service users have the opportunity to visit and “test drive” the home. The arrangements for contracts need to improve to ensure the tenancy rights of service users are safeguarded. EVIDENCE: The home has a statement of purpose and service user guide that was reviewed and updated in April 2005. The information in the statement of purpose and service user guide was clearly written and well presented. The manager stated the home has a policy on admission of service users that was Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 9 dated December 2005. The manager stated a service user was admitted to the home on the 20/12/05 and the home offered the service user the opportunity to visit and meet with staff and service users before admission to the home. The inspector noted the service user had an advocate who visited and assessed the suitability of the home. Observations confirmed the service user interacting with staff, moving freely around the home and sitting at the dining table for tea which indicated improvements in his behaviour based on the information provided. The manager stated the home offered contracts to service users and remarked two service users living at the home had no written contracts. The inspector noted the service users were placed at the home by the local authority (Surrey County Council) as part of the hospital resettlement programme and no written contracts were signed between the provider and the social services for the provision of care. This was discussed with the manager and a requirement has been made for contracts to be issued to safeguard the tenancy rights of service users. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Although there is a care planning system in place it must be improved to reflect care plans based on person centred planning and to ensure staff have information to satisfactorily meet the needs of service users. EVIDENCE: The manager stated the home had service user plans that were regularly reviewed and updated by key workers. The inspector sampled care plans and noted they were reviewed monthly, dated and signed by the key worker and covered areas of personal care, social activities and health needs. The home kept daily records of service users activities for information and monitoring and completed a daily care notes record. The inspector noted one service user had Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 11 a person centred plan dated January 2005 which included a health action plan, an essential life style plan and outlined the service users aspirations and goals. Person centred plans were discussed with the manager and a requirement has been made for all service users living at the home to have an essential lifestyle plan and a health action plan in line with the valuing people white paper on learning disability. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13&16 The arrangements for personal development are satisfactory ensuring service users have opportunities to develop social skills. The arrangements for occupation are adequate ensuring service users are able to take part in culturally appropriate activities. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 13 Links with the community are good ensuring service users are supported to participate in the local community. Daily routines at the home are satisfactory promoting independence and freedom of movement within the home. EVIDENCE: The home had a policy on personal development and the home offered opportunities to service users to attend church service, a local day centre for computer skills training, makaton training and a resource centre for arts and crafts. The manager stated staff had training in makaton to enable them to communicate with service users and the home supported service users to attend relaxation classes which enable service users to remain calm. The home had a policy on community links and social inclusion and the manager stated service users attended activities in the local community which covered going out to the local cafes, meals out to local restaurants, local parks and village pubs. The home provided a ten seater mini-bus to enable service users to access the community. The inspector noted one service user admitted to the home had access to public transport travelling on the local trains which is his preferred activity. Staff were observed to address service users by their preferred names and the manager knocked on doors before entering service users bedroom thereby respecting personal privacy. Observations confirmed service users moving freely in the home and one service user invited the inspector to view his bedroom. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18&20 The arrangements for personal support are satisfactory ensuring service users are supported in the way they prefer. The systems in place for the storage and management of medications needs to improve to safeguard and protect service users. EVIDENCE: The manager stated the home had a flexible routine to take account of service users choices in getting up, going to bed, baths, meals and other activities. Observations confirmed service users were smart in appearance and appropriately dressed and the inspector noted a care staff supporting a service user with personal care in the privacy of the service user’s bedroom. During discussions a service user smiled and nodded his head which indicated he was happy with his key worker who is the deputy manager. The home had a policy on the administration and control of medicines in care homes dated December 2005 and a local policy on service users medications Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 15 dated October 2005. The manager stated staff at the home had training in medications and the inspector sampled staff records and noted the home had a practice assessment for unqualified staff that was dated and signed by the deputy manager to confirm staff competence in the administration of medications. The inspector noted the home did not have a record of staff names with specimen signatures who were deemed competent to give medications and a requirement has been in respect of this matter. The manager stated medication were supplied by Boots Chemists on a monthly basis and medications were checked, dated and signed by staff. The inspector sampled medication record sheets and noted they were dated and signed by staff with no discrepancies. The home had a lockable metal cabinet secured to a wall for the storage of medications and medication keys were kept on the person of the senior care staff on duty. The deputy manager remarked a medication used for the management of epilepsy was stored in the refrigerator which contained food products. This was discussed with the manager and a requirement has been made for the home to provide a small refrigerator to ensure medications are appropriately and adequately stored. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaint process at the home is satisfactory with complaints information available to staff, service users and relatives. EVIDENCE: The home has a complaint policy which was reviewed and updated by the manager in December 2005. The manager stated the home had a complaints folder and remarked the home had no complaints since the last inspection. The inspector sampled the complaint folder and noted no complaints were recorded. During discussions staff stated they were aware of the complaints procedure and remarked “matters of concern were raised with the manager or at team meetings”. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27&30 The home is well maintained ensuring service users live in a safe environment. Bedrooms are adequate and promote the independence of service users however privacy needs to be improved in shared bedrooms. Toilets and bathrooms are sufficient and meet the individual needs of service users. The arrangements for hygiene are satisfactory ensuring the home is clean and hygienic for service users. EVIDENCE: Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 18 The property is located in a residential road and is in keeping with the local community. The home is close to shops and public amenities and the inspector noted on the day of the inspection the home was clean, well ventilated and free from offensive odours. Bedrooms were well presented and personalised with pictures, paintings, family photographs, ornaments, radio, television and all bedrooms doors were lockable. During discussions one service user remarked “Yes, I am very happy with my bedroom”. The inspector noted screens were not available in the shared bedroom to ensure the privacy of service users and action has been required in respect of this matter. Toilets and bathrooms were adequate, clean and hygienic. The inspector noted a toilet was near to the dining area and lounge which was easily accessible by service users. The manager stated staff had training in infection control and the inspector noted staff washed their hands regularly using anti-bacterial hand-wash. Gloves were available in the bedrooms, bathrooms and toilets and hand-washing facilities were sited in the laundry area and kitchen to prevent cross infection. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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&32 The management arrangements at the home are satisfactory ensuring staff have a clear understanding of their roles and responsibilities. The qualities of staff are good ensuring service users are supported by competent staff. The standard for staff training was exceeded at the time of the inspection. EVIDENCE: The manager stated staff have a clear understanding of their roles and responsibilities and remarked staff have job descriptions. The inspector sampled job descriptions and noted they contained information on personal care, activity, domestic tasks and communication. The manager stated the home has an on-call system to provide advice to care staff who may require Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 20 additional support and the inspector noted care staff had a key worker role that enabled them to develop a relationship with service users and promote the aims of the home. During discussions a staff stated the aim of the home was “to provide good care” and remarked service users “must be kept safe at all times”. The inspector noted staff had been issued with the General Social Care Council (GSCC) code of conduct booklet for information. The manager stated the home had an accolade from Skills for Care which reflected the best employer of up to 250 staff and an award from care choices. The inspector noted a certificate was displayed in the home which confirmed the accolade and one staff remarked “the management spends a lot of money on staff training”. Observations confirmed care staff were good listeners and have specialist skills to meet the needs of service users which included training in communication skills and challenging behaviour. The home has contact with the community psychiatrist from the local primary care trust who supports the staff team when necessary. The manager stated all staff working at the home had achieved the National Vocational Qualification (NVQ) in care award and remarked the home had exceeded the 50 targets set. The inspector sampled staff records and noted staff had certificates in National Vocational Qualification (NVQ) issued by City and Guilds. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,41,42&43. The systems at the home for quality assurance are adequate ensuring service users participate in the quality monitoring of the home. Record keeping at the home is satisfactory ensuring service users rights and best interests are safeguarded. The arrangements for safe working practices are adequate ensuring the health, safety and welfare of service users are protected. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 22 The arrangements for the conduct of the home are satisfactory ensuring the home is financially viable and safeguarding the interests of service users. EVIDENCE: The home had a policy on internal audit of the quality system which was reviewed in November 2005. The manager stated the home had regular meetings with service users to obtain feedback about the home. The inspector noted a meeting was held on the 29/11/05 attended by staff and service users to plan and organise Christmas activities and to inform service users of the Commission for Social Care Inspection (CSCI) visit on the 28/12/05. The minutes were signed and dated by the deputy manager. The manager stated the home had annual care plan reviews that were sampled and the inspector noted it was recorded in the minutes relatives “expressed their satisfaction with the standard of care offered at the home”. The inspector noted records at the home were up to date and securely and confidentially stored in a locked cupboard. The home has a policy on health and safety reviewed and updated in December 2005. The manager stated staff had training in food hygiene, fire safety and infection control and refresher training courses were planned for 2006. The home had a legionella test certificate issued on 14/11/05 which was negative, a current gas certificate and a periodic inspection report for electrical installation dated 2/11/04. The home has a management structure which is in the statement of purpose and sets out clear lines of accountability for staff working in the home. A certificate of employers liability insurance dated 11/8/05 was in place and a business plan dated April 2005 which covered staff development, recruitment, quality of care and management. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT 37 X 38 X 39 3 40 X 41 3 42 3 43 3 Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 2 X X X X 3 3 3 X X 3 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 24 No. 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 NMS-YA 5 Regulation 5(1)(b)(c) Requirement The registered person must ensure a contract is provided for service users and a copy included in the service users guide. The registered person must ensure medications are appropriately and adequately stored by providing a small refrigerator designated for the storage of medications. The registered person must ensure a list with the names of staff and specimen signatures is available at the home for information. The registered person must ensure the privacy and dignity of service users by providing a screen in the shared bedroom. Timescale for action 01/04/06 2 NMS-YA 20 13(2) 20/01/06 3 NMS-YA 20 13(2) 20/01/06 4 NMS-YA 26 16(2)(c) 20/01/06 Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 25 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 NMS-YA-6 Good Practice Recommendations The registered person must ensure service users have a health action plan and a person centred plan which identifies service users aspirations and goals. Alexandra House DS0000013549.V256441.R01.S.doc Version 5.0 Page 26 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.V256441.R01.S.doc Version 5.0 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!