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Inspection on 11/01/07 for Alexandra House Care Home

Also see our care home review for Alexandra House Care Home for more information

This inspection was carried out on 11th January 2007.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A kind and caring atmosphere was evident throughout the home. Staff were seen to treat service users with respect and maintained a good rapport. Service users spoken with spoke positively about care received, the staff and life within the home. Visitors are made welcome and are respected by staff. Staff spoken with were able to discuss service users needs and how they are supported in meeting these to a good standard.

What has improved since the last inspection?

Service users are made fully aware of the terms and conditions of the home prior to admission ensuring that they are able to make an informed choice about whether to move in to the home. Decision made with service users and the service prior to admission are upheld ensuring that service users choices are maintained. Service users reviews reflect care received and individual outcomes ensuring continuity of care. Care plans have continued to develop to ensure these are personalised and are meeting individual needs. Medicine arrangements have made some improvement in regards to record keeping; however further improvement is still required. An activities coordinator has been employed to enhance the recreational and social lives of service users. The manager has liaised with the Environmental Health Officer to ensure appropriate documentation in the kitchen is in place, this ensures service users are further protected. Additional staff have been employed to enhance the staff team thus ensuring service users needs are met. Staff continue to work towards completing compulsory training to demonstrate they are knowledgeable and competent in their job role. All policies and procedures have been reviewed to ensure up to date practices are maintained. Service users and relevant others are protected from the risk of slips and falls by using the appropriate wet floor signs at all times. Water temperatures are now recorded monthly ensuring service users are further protected from hot water.

What the care home could do better:

Consent is to be obtained prior to the use of bedrails to ensure service users rights are protected. To ensure plans of care are in place for all identified needs and these accurately reflect the support required by the service users to ensure their needs are fully met. Risk assessments are required to be in place for all identified risks and these are to demonstrate how these will be managed to ensure service users are fully protected. The responsible individual is to ensure the safe receipt; administration, recording and disposal of medication to ensure service users are fully protected. To make good or replace the ramp leading into the main entrance of the building to ensure service users and others are protected. Fix the remaining bed headboards to the bed to ensure service users are protected. Forward a maintenance / redecoration plan to the commission to identify when proposed work is to take place to show commitment to ensuring service users live in a comfortable and well maintained environment. To reassess the current induction programme to ensure that staff are trained appropriately to the work they are to perform. Staff employed are required to have POVA 1st checks in place and must work under supervision until receipt of a satisfactory criminal record bureau check to ensure service users are fully protected.All staff employed are required to have documentation on file as listed in schedule 2 to ensure service users are protected. The acting manager is required to apply to become the registered manager to ensure the home is run and managed by a person who is fit to be in charge. Further consultation with the fire authority is required to ensure adequate precautions are taken against the risk of fire. Five good practice recommendations were also made, for further information on these please access the full body of the report.

CARE HOMES FOR OLDER PEOPLE Alexandra House Care Home Wroughton Court 191 Nottingham Road Eastwood Nottingham NG16 3GP Lead Inspector Karmon Hawley Key Unannounced Inspection 11th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Care Home Address Wroughton Court 191 Nottingham Road Eastwood Nottingham NG16 3GP 01773530601 01773710924 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) Eastgate Limited Vacant Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Terminally ill (2) of places Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for 38 service users these shall be within category OP 2 service users may be in the category TI included within the total 10th October 2006 Date of last inspection Brief Description of the Service: Alexandra House is purpose built providing nursing and residential care for older people. It is situated in a quiet cul-de-sac in the outskirts of Eastwood, close to local shops, pub, church and bus route into the centre of Eastwood and the nearby city of Nottingham. There are pleasant gardens and a car park to the front and side of the building. There are various seating areas within the home and two separate dinning rooms. Service users rooms are decorated to a satisfactory standard and are personalised. The building is accessible for wheelchair users and there is a lift to the upper floor. The current fees for the home which are made available on the point of enquiry are as follows: nursing, local authority county council £392, city council £426, private £445, MAY Scheme £426 - £476. High dependency residential local authority county council £319, city council £307.96, private £350. Residential local authority county council £277, city council £272.58, private £325 and additional charge of £20 is applicable for an ensuite room. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. The unannounced site visit took place in six and a half hours and was performed by one inspector. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users and one relative were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were satisfied with the staff, care received and the standards within the home. The acting manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: What has improved since the last inspection? Service users are made fully aware of the terms and conditions of the home prior to admission ensuring that they are able to make an informed choice about whether to move in to the home. Decision made with service users and the service prior to admission are upheld ensuring that service users choices are maintained. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 6 Service users reviews reflect care received and individual outcomes ensuring continuity of care. Care plans have continued to develop to ensure these are personalised and are meeting individual needs. Medicine arrangements have made some improvement in regards to record keeping; however further improvement is still required. An activities coordinator has been employed to enhance the recreational and social lives of service users. The manager has liaised with the Environmental Health Officer to ensure appropriate documentation in the kitchen is in place, this ensures service users are further protected. Additional staff have been employed to enhance the staff team thus ensuring service users needs are met. Staff continue to work towards completing compulsory training to demonstrate they are knowledgeable and competent in their job role. All policies and procedures have been reviewed to ensure up to date practices are maintained. Service users and relevant others are protected from the risk of slips and falls by using the appropriate wet floor signs at all times. Water temperatures are now recorded monthly ensuring service users are further protected from hot water. What they could do better: Consent is to be obtained prior to the use of bedrails to ensure service users rights are protected. To ensure plans of care are in place for all identified needs and these accurately reflect the support required by the service users to ensure their needs are fully met. Risk assessments are required to be in place for all identified risks and these are to demonstrate how these will be managed to ensure service users are fully protected. The responsible individual is to ensure the safe receipt; administration, recording and disposal of medication to ensure service users are fully protected. To make good or replace the ramp leading into the main entrance of the building to ensure service users and others are protected. Fix the remaining bed headboards to the bed to ensure service users are protected. Forward a maintenance / redecoration plan to the commission to identify when proposed work is to take place to show commitment to ensuring service users live in a comfortable and well maintained environment. To reassess the current induction programme to ensure that staff are trained appropriately to the work they are to perform. Staff employed are required to have POVA 1st checks in place and must work under supervision until receipt of a satisfactory criminal record bureau check to ensure service users are fully protected. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 7 All staff employed are required to have documentation on file as listed in schedule 2 to ensure service users are protected. The acting manager is required to apply to become the registered manager to ensure the home is run and managed by a person who is fit to be in charge. Further consultation with the fire authority is required to ensure adequate precautions are taken against the risk of fire. Five good practice recommendations were also made, for further information on these please access the full body of the report. 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. The summary of this inspection report can be made available in other formats on request. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. 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. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users may be assured their needs will be assessed and met prior to admission. The home does not offer intermediate care. EVIDENCE: The manager visits prospective service users in the community and a preadmission assessment is carried out prior to admission. The preadmission assessment covers the requirements of the standard and there was evidence within service users files to confirm that these take place. Service users and relevant others may also visit the home should they wish. The manager discussed how negotiations may take place prior to admission and stated that it is ensured that any decisions taken prior to admission is able to be upheld by staff. The manager also stated that it is ensured that all service users and their Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 10 relatives have the relevant information required prior to admission. One service user spoken with said that they received all the required documentation before admission and their relatives had visited the home. Staff spoken with were able to confirm that this process takes place. The home does not offer intermediate care services. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users 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. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individual plan of care, significant improvements have been made however further development is still required in respect of risk assessments and ensuring appropriate plans of care are in place for mental health care needs and nutritional care needs. Service users health care needs are fully met. Slight improvements have been made in medication procedures; however further development is still required to ensure service users are fully protected. Service users feel they are treated with respect and their rights to privacy is upheld. EVIDENCE: Service users undergo various assessments with regard to the activities of daily living, manual handling, infection and nutrition; information gained forms the basis of the plan of care. Plans of care in place have continued to develop since the previous inspection they are more personalised and identify needs Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 12 and preferences. Within one service users file there was a personal profile which offered a good insight into that person and their needs. Plans of care were in place for the majority of needs highlighted however within one plan of care relating to dementia care needs there was no plan in place. In another case file there was a plan for mental health needs, but the information on support required was limited. Risk assessments had taken place, however where a risk of falls had been identified within one plan of care there was no management plan, also within another the management plan was brief. Where a high nutritional risk was highlighted there was no plan of care in place. Of three case files examined bedrails were in use, within two there was no consent forms to demonstrate this had been gained and there were no risk assessments in place for the risk of entrapment. Daily records were maintained and contained information with regards to significant events. Reviews take place on a monthly basis to reflect service users current care needs. Service users spoken with stated that their needs were met and staff were kind and considerate. Staff spoken with were able to discuss service users needs and how they support them in meeting these. There was evidence seen within service users plans of care to show that the multidisciplinary team and specialist services are accessed as required. Relevant equipment such as specialist mattresses and cushions were seen during the tour of the home. Two service users spoken with said that they may access these services as needed. Staff spoken with confirmed this. Policies were in place for dealing with medicines. Four service users medication charts were checked against the prescription, not all these corresponded. One chart seen showed a heart medicine had been signed for but not administered. Allergies and medical conditions were detailed on the medication chart. Hand written entries seen were not signed by two members of staff to show that these had been checked as correct. There were a number of gaps in the administration of some medications such as inhalers, and ointments therefore records of these being administered as prescribed were not complete. The British national formulary was dated 2004. There were no records of room temperatures; the temperature during the inspection was 26 oC this may affect some of the medicines stored in this room if they are required to be stored at a lower temperature. Fridge temperatures are recorded on a daily basis, however there were three days where this had not been carried out. The manager said that staff are instructed on maintaining service users privacy and dignity. Staff spoken with were able to discuss these issues and how they maintain this whilst assisting service users. Staff were observed to treat service users with respect and privacy was upheld. Service users spoken with stated that staff were respectful and their privacy was maintained. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their needs, however several service users feel that further activities would prove beneficial. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing diet in pleasing surroundings. EVIDENCE: An activity coordinator has been employed for ten hours a week who offers activities 2hours a day five days a week. The manager said that this post is still developing and notices of events and activities are to be displayed in the near future. Outside entertainment is also provided on occasion. Service users spoken with were happy and content with activities on offer however two service users expressed that they wished there was more to do. Some service users entertain themselves playing dominoes if able. A church service is also held in the home should service users wish to attend. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 14 Staff stated that the routine of the home is flexible and service users may choose how they spend the day. One service user spoken with requested to go to their room, this request was upheld. All service users spoken with said that they may choose how they spend their day and that staff were kind and respectful and listened to their needs. There are no restrictions on visiting and visitors may be received in private. One service users spoken with stated they have many visitors and they are always made welcome. One visitor was spoken with who said that they were made welcome and staff were approachable. Staff were able to discuss how they ensure that service users are treated as individuals, their life experiences are respected and service users rights and choices are upheld. Service users spoken with said that they felt that they were treated as an individual and they were respected. A choice of meal is offered at meal times, which service users confirmed. Service users spoken with stated meals were a good standard and were plentiful. The menu observed was wholesome and appealing. Specialist diets are catered for. The kitchen was clean and tidy and records to demonstrate that temperature recording and cleaning takes place as appropriate were available. The Environmental Health Officer has recently visited the home and four requirements were set. These related to repair of the insect screen door, attention to the rusty lid on the small chest freezer, the timber shelving in the food store to be resealed and issues around disposal. A copy of the safer food better business documentation was left at the home. This has not as yet been implemented. The manager said that the provider is aware of the requirements and is working towards completing these. Outside the kitchen door was a small amount of rubbish that consisted of old equipment and furniture. The manager said that a skip is to be ordered to remove this. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users and relevant others may be assured their complaints will be listened to taken seriously and acted upon. Service users are not fully protected from abuse. EVIDENCE: Relevant complaints policies are in place. There has been one complaint made since the previous inspection. Records seen showed that this had been dealt with appropriately. Staff spoken with were able to discuss how complaints would be dealt with if received. Service users spoken with expressed no complaints with the care received. Not all the staff have either current Criminal Record Bureau checks in place or Protection of Vulnerable Adult checks in place. (POVA 1st) the manager said that all staff who do not have a Criminal Record Bureau check in place work supervised. There was a daily allocation book in use for this purpose. A statutory requirement notice has been served requiring rectification of the deficiencies in regards to the recruitment of staff. Training in adult protection has been booked for the near future, dates for this was seen on the training matrix. Staff spoken with were able to discuss issues with regards to the protection of vulnerable adults and what they would do in the event of this occurring. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. 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. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in an adequately maintained environment, however improvements are necessary. The home is clean, pleasant and hygienic. EVIDENCE: The lounge has been redecorated and the manager said there are plans to redecorate the dining room within the next week. Other areas of the home are now in need of redecoration, such as corridors and the small sitting room. The ramp leading in to the building is in a poor state of repair and may cause a hazard. The carpet in the small sitting room remains stained. The manager said that the majority of headboards have now been fixed to the beds, those seen had been done. Some new beds have been purchased and additional specialist mattresses. The gardens were satisfactorily maintained. The laundry room was clean and tidy and appropriate equipment in place. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 17 The home was clean and tidy and free from offensive odour. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. 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 home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the number and skill mix of staff. Service users may not be in safe hands at all times as the induction programme requires updating and it is recommended that further staff undertake the National Vocational Qualification. Service users are not supported and protected by the homes recruitment policies and practices. Staff continue to work towards completing compulsory training ensuring they are trained and competent to do their jobs. EVIDENCE: Staff rotas were observed which demonstrated that sufficient staff for the number of service users are employed, staff spoken with confirmed this and said that staffing levels were much improved. Service users spoken with said that staff were available when needed. Six members of staff have attained the National Vocational Qualification (a nationally recognised theory and work based qualification), and two are working towards this qualification. One member of staff has attained level three. The induction programme remains as previous and does not relate to the Skills for Carers Standards therefore the induction programme lacks in essential areas of training and induction. The manager said that the administrator was looking at improving this. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 19 Four staff personal files were observed, not all the required documentation as listed in schedule 2 was available, such as photographic evidence and written identification, this was discussed with the manager who said that he had begun working towards completing this, photos taken to date were seen. A list of all new staff members and criminal record status was recorded; two members of staff had no POVA 1sts in place. The manager contacted the administrator who said that these had been obtained but no records were available, therefore the agency was contacted and the status of these checked. The manager said that the agency said that they were still waiting for these to be returned from the police. Staff training records demonstrated that a continual programme of staff training is now in place and staff are working towards completing compulsory training. A number of courses in manual handling, fire safety and health and safety has taken place, first aid and the protection of vulnerable adults and dementia awareness has been booked. Staff spoken with said that training was at a good standard and they felt supported. Service users and the relative spoken with stated that staff were kind and caring and were respectful at all times. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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 home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is in the process of submitting his application to the Commission for Social Care Inspection to become the registered manager. Further evidence is available to show that the home is run in the best interests of service users, however additional evidence would prove beneficial. Service users financial interests are safeguarded. The health safety and welfare of service users is not fully promoted and protected. EVIDENCE: A new acting manager commenced employment in October 2006 and is in the process of applying to become the registered manager. He has previous managerial experience. He does not intend to complete the Registered Managers Award however he has completed a 6month health service Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 21 management training course in 1990. He said he ensures that he keeps up to date with compulsory training. Staff spoken with spoke highly of the manager and said that he was approachable and had time for both staff and service users. Service users spoken with expressed no concerns with regards to the management of the home. The manager sent out questionnaires to relatives and service users and has collated the results. Out of 36 sent 25 were returned. Outcomes were both positive and negative; positive - that the home is always clean and tidy and they can always speak to nurses and negative the lack of private areas and seating, not always easy to gain access. The manager plans to address all negative issues. The provider has sent one monthly report to the Commission for Social Care Inspection following a visit to the home outlining progress made. The majority of policies and procedures have now been reviewed. The provider does not deal with service users personal finances and is not responsible for any of these. Relevant maintenance and servicing certificates such as the portable appliance testing, the gas certificate and lift certificate were seen. Water temperatures are now tested on a monthly basis. Accident records seen contained the required information and action taken. The Fire Authority visited the home in November 2006 and set a number of requirements with regard to the fire alarm system checks, a further visit is planned to observe compliance with these. On looking at the fire logbook, fire alarm systems had not been tested on a weekly basis and emergency lights had not been tested since March 2006. The manager said that this had been done, however the records were not available to confirm this. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 12(2) Requirement Consent is to be obtained prior to the use of bedrails to ensure service users rights are protected. Ensure plans of care are in place for all identified needs and these accurately reflect the support required by the service users to ensure their needs are fully met. Risk assessments are required to be in place for all identified risks and these are to demonstrate how these will be managed. This is an outstanding requirement and has been ongoing since 14th June 2005 and must be addressed. The responsible individual is to ensure the safe receipt; administration, recording and disposal of medication to ensure service users are fully protected. This is an outstanding requirement and has been ongoing since 17th March 2005 and must be addressed. Make good or replace the ramp leading into the main entrance of the building. DS0000026407.V326240.R01.S.doc Timescale for action 20/02/07 2 OP7 15(1) 11/03/07 3 OP7 13(4,c) 09/02/07 4 OP9 13(2) 09/02/07 5 OP19 13(4,c) 20/02/07 Alexandra House Care Home Version 5.2 Page 24 6 7 OP19 OP19 13(4,c) 23(2,b) 8 OP28 18(c,i) 10 OP29 19(1,b) 11 OP31 8(1) 12 OP38 23(4,a,c) Fix the remaining bed headboards to the bed. Forward a maintenance / redecoration plan to the commission to identify when proposed work is to take place. To reassess the current induction programme to ensure that staff are trained appropriately to the work they are to perform. All staff employed are required to have documentation on file as listed in schedule 2 to ensure service users are protected. This is an outstanding requirement and has been ongoing since 14th June 2005 and must be addressed. The acting manager is required to apply to become the registered manager to ensure the home is run and managed by a person who is fit to be in charge. Further consultation with the fire authority is required to ensure adequate precautions are taken against the risk of fire. 20/02/07 20/02/07 20/03/07 09/02/07 20/02/07 20/02/07 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 4 Refer to Standard OP12 OP15 OP28 OP31 Good Practice Recommendations Continue to develop the role of the activities coordinator and promote activities on offer. Implement the safer food better business documentation. 50 of staff are trained at the National Vocational Qualification level 2. The induction programme is further developed. The acting manager undergoes the registered managers award. DS0000026407.V326240.R01.S.doc Version 5.2 Page 25 Alexandra House Care Home 5 OP33 To further develop the quality assurance systems in place. Alexandra House Care Home DS0000026407.V326240.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Care Home DS0000026407.V326240.R01.S.doc Version 5.2 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. 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