Inspection on 04/03/04 for Alexandra House

Care Home For Older PeopleAlexandra House1 Narborough Road Huncote Leicestershire LE9 3ANAnnounced Inspection4th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Alexandra House Address 1 Narborough Road, Huncote, Leicestershire, LE9 3AN Email Address Name of registered provider(s)/Company (if applicable) Mrs Jacqueline Ann Skubala Mr Albert Konrad Skubala Name of registered manager (if applicable) Mrs Jacqueline Ann Skubala Type of registration Care Home No. of places registered (if applicable) 17 Tel No: 0116 2753669 Fax No: noneCategory(ies) of registration, with (number of places) Old age, not falling within any other category (17) Registration number C010000553 Date First registered 5th November 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 5th November 2003 NO YES N/A If Yes Refer to Part CAlexandra HousePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 34th March 2004 09:30 am Keith Charlton Helen AbelID Code071392Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mrs Jacqueline Ann Skubala the time of inspectionAlexandra HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementAlexandra HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Alexandra House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Alexandra HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. This is a newly registered home for Older People. It is situated in the village of Huncote. There are local facilities nearby. Service users all enjoy the benefit of a single bedroom with toilet en suite. There is a choice of lounge/dining rooms and a good size garden to the rear. The Home has a friendly Labrador dog who provides companionship to service users.Alexandra HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The focus of Year 2 inspections undertaken by the National Care Standards Commission is upon outcomes for service users, progress on meeting national minimum standards from Year 1 inspections and focusing on aspects of service provision that need further development or pose the most significant potential risk to service users. This is the first inspection for the home and focuses on the areas that are significant for service users lives. On the day of the inspection it was again found that there was a very relaxed atmosphere amongst service users. Alexandra House is commended for its overall care and support offered to service users The Home has only a relatively small number of requirements following this inspection, which is testimony to the hard work it has put in to meet National Standards. Choice of Home The Home has a Statement of Purpose and Service User Guide which needs to be collated to be available to service users /representatives. See Requirement 1. All service users within the Home have a contract, to which they have a copy. Assessments for prospective service users are detailed encompassing major areas of care. The Home within its Statement of Purpose and Service User Guide details how the home can meet the needs of service users. The Home is to carry out training to cover all service users conditions. See Requirement 2. Health and Personal Care The Home has a number of policies and procedures incorporating privacy and dignity, the care of service users during illness and dying. The Home has care plans for service users, which are regularly reviewed and updated. Service users /representatives need to be involved in setting then up and agreeing to them. See Requirement 3. Service users health care needs are monitored and recorded as appropriate, all service users having access to Doctors, Dentists, Chiropodists etc. as required. The home manages medication within the Home, which is regularly monitored to ensure standards are maintained. Service users can manage their own medication if required ­ this is commended. Alexandra House Page 6 Daily Life and Social Activities The Home has a number of in-house activities, and events both internally and externally are organised by the Home. There was evidence of differing types of activities arranged by the home. Service users are asked which choice they wish to have for all meals. Meals within the Home are of a very high standard according to service users and service users were very complimentary. Complaints and Protection The homes procedure need to cover all relevant issues in terms of the complainant being able to go to the Commission, rather than the home, if they choose. See Requirement 4. Policies and procedures on service users finances are needed. See Requirement 5. Environment The Home offers single bedrooms for all service users. The Home has a variety of communal areas, and a large garden to the rear. The Home is decorated and provides furnishings to a good standard that suits service users in both communal areas and individual bedrooms. The Home has adaptations and equipment, which meets the current needs of service users. The home was found to be very clean and tidy which is testimony to the staff, and service users were very complimentary about this. Staffing The Home set out a staffing ratio to meet both the care needs and ancillary needs of service users. However it was found that with 5 service users and 1 service user due to be admitted the following day, staffing levels of always having 2 staff on duty for the day and evening were needed to meet the requirements of the Commission. See Requirement 6. Staff within the Home receive induction training, and on going training relevant to the work they perform. The Home operates a recruitment process, and holds records relating to staff.Management and Administration Alexandra House Page 7 The Registered Manager has considerable experience in managing and running a residential home. The Home seeks the views of service users. It now needs to develop a Quality Assurance System, which seeks the views of all stakeholders and publishes the results. See Requirement 7. Staff within Home need to receive regular supervision. See Requirement 8. The Home ensures that all systems within the Home are serviced with records kept ­ some records need more detail. See Requirement 9. Risk assessments on safe working practices need to be in place and further Moving and Handling training is needed with food hygiene training needed for 1 staff member. See Requirement 10. Service User Comments Service user comments were very positive. For example It is a very nice home. Staff are very good I am very happy with the home. Very nice, staff are all friendly. Meals are perfectly good. ` Staff are lovely. ` It is idyllic. Congenial atmosphere. The food is excellent. You can ask for what you want. Staff and management are highly commended for this positive and caring picture of residential care.Alexandra HousePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Alexandra HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 4 OP1 The Registered Manager needs to collate all relevant information and produce a comprehensive Statement of Purpose including the Service users Guide. Staff need to receive training in dementia well as conditions that current service users have ­ diabetes, Parkinsons Disease and partially sighted. The Registered Manager stated that they will involve all parties in setting up the care plan and that the service user/ representative will sign it. 4.6.04212OP44.6.04315OP74.5.04422OP16The Complaints Procedure needs to be slightly amended to state that the complainant 4.4.04 can go to the National Care Standards Commission at any stage. Policies and procedures on service users finances are needed. The Home needs to have a minimum of 2 staff covering in the daytime and evening periods. 4.6.04517OP18618OP275.3.04Alexandra HousePage 10 724OP33The home is to organise a yearly internal audit and have a continuous self monitoring method (e.g. the Investors in People programme the home has should cover this) and to organise and publish service users and stakeholders surveys. Care staff need to have a minimum of 6 Supervision sessions per year tom include all aspects of this National Standard. Fire records need to show that fire drills are carried out 3 monthly.4.9.04818OP364.5.04 5.3.04 4.4.04917OP37Emergency Lighting tests need to be carried out monthly. Medication records need to always use coding e.g. r = refused.4.3.04The production of a Fire Risk Assessment is needed. 10 12 OP38 Moving and Handling Training is needed and food hygiene training for 1 staff member. The home needs to produce risk assessments regarding safe working4.4.044.6.04 4.6.04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard *Alexandra HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) NO YES YES YES YES YES NO No YES NO YES NO YES YES NO NO NO YES NO YES 3 0 0 NO NO YES YES 3 2 4/3/04 09.30 5.5Alexandra HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Alexandra HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service Users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 350 To (£) 400Any charges for extrasYESIf yes, please state what the extras are: Hairdressing, chiropody, transport, toiletries, holidays Key findings/EvidenceStandard met?2The home has largely completed this standard by the current information it holds. This now needs to be collated to produce a comprehensive Statement of Purpose and Service Users Guide. The Registered Manager is to look at this National Standard and produce this document. See Requirement 1. The home is to add a copy of the most recent Inspection Report.Alexandra HousePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The home carry out their own assessment as well as the assessment carried out by the Social Services Department. The assessment form largely mirrors that outlined in the national and the Registered Manager is to add oral hygiene to this form.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The home stated that it was felt that staff generally have the skills and knowledge to deliver the care the home offers to provide and stated that staff are to receive training in dementia well as conditions that current service users have ­ diabetes, Parkinsons Disease and partially sighted. See Requirement 2.Alexandra HousePage 15 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not admit service users for intermediate care.Alexandra HousePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? All service users have a well presented Care Plan. Written risk assessments have been completed. The care plan is reviewed by the home on a monthly basis- this is commended. The Registered Manager stated that they will involve all parties in setting up the care plan and that the service user/ representative will sign it. See Requirement 3.Alexandra HousePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence0 1 3Standard met?The Registered Manager stated that staff maintain the personal and oral hygiene for all service users and support the service users own capacity for self care. The home has a special mattress and cushions for those service users who have or at risk of having pressure sores. The home encourages walks and staff assistance is available for this. The home has set up a system of annual dental and optical check ups and offer to arrange hearing tests on admission if this appears a problem. Chiropody is provided privately or through the NHS. The home has a form for nutritional screening information in care plans and has obtained information on the National Service Framework for older people ­ this is commended.Alexandra HousePage 18 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The home stated that at present there are service users who self medicate. The home has a policy on this and offers this on admission if risk assessed as feasible ­ this is commended. The home has policies and procedures on medication administration and will check with the homes pharmacist as to his approval of policies and procedures. Controlled drugs are stored in a glass fronted cabinet. The home needs to check with the pharmacist whether this meets regulations requirements. Medication records were generally well kept. The homes staff who issue medication have attended a 12 week College course to gain accreditation.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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 maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? The home has an activities programme. Service users appeared satisfied with this. Service users can have meals at times they choose according to the Registered Manager. There is contact with the local church and the home is trying to regain contact with input from the Catholic church and the home stated it would arrange other denominational visits if requested. The home Terms and Conditions outline flexibility of routines and choice in lifestyles.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users spoken to thought that the home had a minimum of restrictions ­ this is commended. The Registered Manager stated that service users and their representatives can contact advocacy services and this is displayed on the notice board. Service users can bring their personal possessions with them. There is access to personal records by service users if wished.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? Service users spoken to all stated that the homes food is of a very high standard ­ this is commended. There are choices for every meal and menus look impressive - vegetables served have been recorded. The Registered Manager stated that currently there are no special diets though the diabetic service user is catered for with appropriate cakes and desserts.Alexandra HousePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence The home has a generally good complaints procedure. This needs to be slightly amended to state that the complainant can go to the National Care Standards Commission at any stage. See Requirement 4. 0 X X X X 0 X 2Standard met?Alexandra HousePage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 2The Registered Manager stated that she will ensure that all staff understand the `No Secrets document and is to consider producing a simple procedure of what needs to be carries out if abuse is found, alleged or suspected. Policies and procedures are needed for service users access to personal financial records, safe storage of money and valuables, consultation on finances in private, advice no personal insurance and precluding staff from being involved in the making or benefiting from service users wills. See Requirement 5.Alexandra HousePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home appears well maintained. This is commended. The home needs a record of routine maintenance. The home needs to complete a fire risk assessment. The Registered Manager stated that requirements as per the Environmental Health Department have been attended to except for food hygiene training for 1 staff member.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence YES NO NO 17 17 0 0 Standard met? 2 2 X0 0 0 0The Registered Manager is to insert information in the homes Statement of Purpose to state that 2 single bedrooms are not of the National Standard size. See Requirement 1.Alexandra HousePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Rooms are centrally heated and the service user can control heating. The Registered Manager stated that radiators have been guarded and pipework will be checked to see whether there is any unguarded pipework. The home stated that water is stored at an appropriate temperature to prevent legionella. The water temperature from the tap was tested and found to be below 43c, which is the National Standard. The Registered Manager is aware some bedrooms facing the supporting garden wall are not bright and will ensure they have sufficient lighting to counteract this.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home is kept to a good level of cleanliness and hygiene. Policies and procedures are in place for the control of infection. The home stated that the washing machine meets disinfection standards. There is no current problem with incontinence but if there is the Registered Manager stated the home will look at replacing the washing machine with one that has a sluice in it. The home stated that there are double check valves that comply with the Water Supply Regulations 1999.Alexandra HousePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 1 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 2 2 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X1 3 0 Standard met? 2Alexandra HousePage 28 This inspection has taken into consideration the number of staff hours as required by the Residential Staffing Formula as detailed above. However, as there were 5 service users, 1 of whom has been diagnosed with dementia, and 1 further service user due to be admitted the following day, the Home needed to have a minimum of 2 staff covering in the daytime and evening periods. There were some afternoon and evening periods where this was not the case. The Registered Manager stated that this would be arranged immediately. See Requirement 6. There were no staff members aged under 18 providing personal care and no staff members in charge of shifts under the age of 21.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence 0 0 Standard met? 3The home is aware of this requirement and is actively dealing with it as care staff will be encouraged to complete National Vocational Qualification 2 ­ this is commended.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home is aware that new care staff will need to go through NATIONAL TRAINING ORGANISATION (Training of Personal Social Services) induction and foundation training and has already accessed this ­ this is commended. . The home stated that all staff will receive a minimum of 3 paid days training per year.Alexandra HousePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The home is aware that the manager needs to complete National Vocational Qualification level 4 and has taken steps to try to enrol on the September 2004 course. There are clear lines of accountability within the home. The Registered Manager has over 10 years experience of providing residential care.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The home stated it will produce an annual development plan. The home is to organise a yearly internal audit and have a continuous self monitoring method (e.g. the Investors in People programme the home has should cover this) and to organise and publish service users and stakeholders surveys. See Requirement 7. Service users were informed of this announced inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This Standard was not inspected. It will be inspected at the next inspection later in the year.Alexandra HousePage 32 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 0 1 0 0This Standard was not inspected. It will be inspected at the next inspection later in the year.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 1 Key findings/Evidence Standard met? The home stated that will staff receive 6 supervision sessions per year and this will include aspects of practice, philosophy of care in the home and career development needs. See Requirement 8.Alexandra HousePage 33 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The home generally keeps good records e.g. care records are very comprehensive and well presented. Medication records need to always use coding e.g. r = refused. Fire records need to show that fire drills are carried out 3 monthly and Emergency Lighting tests are carried out monthly. See Requirement 9.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The home stated that all aspects of this standard are covered except the production of a Fire Risk Assessment, Moving and Handling Training is needed and food hygiene training for 1 staff member and the home needs to produce risk assessments regarding safe working practices in the home. See Requirement 10. The Registered Manager stated that currently restrictors are not required on windows. The Registered Manager stated that there are trained first abiders available for all shifts.Alexandra HousePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance 1. The Home has a named variation for the category OP/MD/DE for 1 service user. CommentsCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateKeith Charlton Not Applicable Roger BluffSignature Signature SignatureAlexandra HousePage 35 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsNot ApplicableSignatureIt should be noted that all NCSC inspection reports are public documents.Alexandra HousePage 36 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 4.3.2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAlexandra HousePage 37 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 8th April 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOAlexandra HousePage 38 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 We, Mr. And Mrs. Albert and Jacqueline Skubala, of Alexandra House, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 We, Mr. And Mrs. Albert and Jacqueline Skubala, of Alexandra House, are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Alexandra HousePage 39 - 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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