CARE HOME ADULTS 18-65
Alexandra House 87 Alexandra Road Addiscombe Croydon Surrey CR0 6EZ Lead Inspector
Margaret Lynes Unannounced Inspection 6th January 2006 09:30 Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 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 DS0000025810.V275018.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Alexandra House Address 87 Alexandra Road Addiscombe Croydon Surrey CR0 6EZ 020 8656 2232 020 8656 2232 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) Mr James Emmanuel Kwabena Safo Mrs Bernadette Joan Redmond Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: Alexandra House is a semi-detached building set in a residential area of Croydon and is indistinguishable form any other house in the street. It provides for a family type dwelling for its five service users who have a past or present mental illness. Each service user has their own bedroom, all of which are of an acceptable standard of décor and furnishing. The home is situated within easy reach of Croydon town centre, and near to bus routes and local amenities. The stated aim of the home is to provide a safe and suitable environment that is friendly and homely, and to base its service on a service users right to respect, dignity, independence and flexibility for choice rights and fulfilment. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of several hours, and focused on determining if the eleven requirements that were contained in the last inspection report had been met. Of those eleven requirements, five had been fully dealt with, two partially met, while four remained outstanding. Four of these five relate to premises and staff training issues which fall outside the remit of the acting home manager. The proprietor needs to take action to resolve these matters so that they do not need to be repeated in future reports. What the service does well: What has improved since the last inspection? What they could do better:
The proprietor must take action with regard to the outstanding requirements relating to the premises. Parts of the home are starting to look jaded, and some refurbishment is needed. The manager must continue in her efforts to ensure that her staff team takes all the necessary steps to ensure that the medication administration records are accurately completed at all times. It would be of considerable concern if this requirement had to be repeated in future reports. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 6 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 DS0000025810.V275018.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Two errors were found in the medication administration charts, which means that the Inspector was not satisfied that service users were adequately protected by the home’s procedures for handling medication. EVIDENCE: The medication administration charts were well presented, clearly written and, in the main, accurate. It was unfortunate that a member of staff had failed to sign the records on two separate occasions. The manager had already identified this omission and had raised the matter with the staff member concerned. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Following a previous requirement the complaints procedure had been revised and now offers service users a satisfactory means of raising concerns and complaints, and, provided that the procedure is adhered to, should mean that service users can be confident that their views will be listened to and acted upon. The home has a satisfactory adult protection procedure in place, which means (again with the proviso that the procedure is followed) that service users should be protected from abuse, neglect and self harm. EVIDENCE: It was noted at the last inspection that the complaints procedure did not contain confirmation that service users could raise complaints directly with the Commission, without going through the home’s procedure first. This procedure has now been appropriately amended. It was of surprise at the last inspection that the staff policy and procedure manual did not contain a procedure re the protection of vulnerable adults. This has been rectified. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Due to unmet requirements regarding the premises, it was not felt that the home provided as comfortable and homely environment as it could and should. EVIDENCE: Following the last inspection six requirements were made with regard to Standard 24. Of these, the ones relating to the replacement of the dining room carpet and new lights for the first floor hallway have been met. The necessary refurbishment of the staff WC has been partially completed. Three requirements have not been dealt with – these relate to the replacement of the door to the ground floor storage area, the refurbishment of the kitchen (albeit some improvements had been made), and the need to re-enamel or replace the bath. It was also noted that the manager had identified a number of areas in the home which required refurbishing, including replacing the ground floor hallway and stair carpets, and redecorating the lounge and one of the bedrooms. Although these issues had been brought to the attention of the proprietor in the summer, work has yet to be completed. The proprietor should make every effort to ensure that once identified, action to rectify these matters is undertaken with the minimum of delay.
Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 It was not felt that service users individual and joint needs were being as fully met as they could be as staff had still not been given specific training in mental health issues. EVIDENCE: Following the last inspection (and indeed the inspection that preceded it) it was required that staff be provided with training in mental health issues. It is disappointing that this has yet to take place, particularly given that the proprietor has his own training agency. The manager gave assurances that this training was due to commence shortly. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Improvements have been made in the quality assurance systems in use in the home, which means that service users’ rights and best interests are safeguarded and promoted. EVIDENCE: The previous inspection led to a requirement regarding the need for the proprietor to ensure that any issues arising out of quality assurance checks were promptly dealt with. Checks of the QA system on this visit indicated that matters had improved. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 3 X X X x Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 Requirement The proprietors must ensure that the staff team are provided with training specific to meeting the needs of the service users. The previously set timescale has again not been met. The manager must ensure that the medication administration records are accurately maintained at all times. The previously set timescale has not bee met. The kitchen requires refurbishment, including a diffuser for the fluorescent light. The previously set timescale has not been met. A new door is required to the storage area on the ground floor. The previously set timescale has not been met. The bath requires reenamelling/repacement. The previously set timescale has not been met. The staff WC requires redecorating and a new floor covering laid. The previously set timescale has not been fully met. Timescale for action 28/02/06 2. YA20 13 06/01/06 3. YA24 23 28/02/06 4. YA24 23 28/02/06 5. YA24 23 28/02/06 6. YA24 23 28/02/06 Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA24 YA24 YA39 Good Practice Recommendations The lounge would benefit from redecoration. The bathroom/Wc would benefit from redecoration. It would be good practice to ensure that the results of service user surveys are publicised. Alexandra House DS0000025810.V275018.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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