Inspection on 17/11/05 for Alexandra House Care Home

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

Other inspections for this house

Alexandra House Care Home 11/01/07

Alexandra House Care Home 06/07/06

Alexandra House Care Home 14/06/05

Alexandra House Care Home 01/11/04

Alexandra House Care Home 29/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Alexandra House Care Home Wroughton Court 191 Nottingham Road Eastwood Nottingham NG16 3GP Lead Inspector Karmon Hawley Unannounced Inspection 17th November 2005 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.V262015.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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.V262015.R01.S.doc Version 5.0 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.V262015.R01.S.doc Version 5.0 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 9th April 2003 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. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of three 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. Five service users and two relatives were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those service users spoken with were happy with the care received and the standards within the home, the relatives also expressed no concerns. The acting manager assisted in the inspection process, as did the administrator and one member of staff. Staff demonstrated a caring atmosphere and that a good rapport was maintained with service users. The purpose of this inspection was to assess the remaining core standards and the requirements set at the previous inspection and therefore the report should be used in conjunction with the previous inspection report. During the inspection it became apparent that 13 staff members were in employment without valid criminal records bureau checks in place, therefore a considerable amount of time during the inspection was spent dealing with this issue and ensuring the health and safety of service users within the home. What the service does well: Service users spoke highly of care received and stated it felt homely and staff were nice and treated them with respect; food was nice, plentiful and at a good standard. There was evidence of a good rapport between service users and staff and that good standards of care are maintained. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 7 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.V262015.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed during this inspection. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Service users needs may be compromised due to the lack of assessments, plans of care in place, and inconsistent reviews, they are also placed at a degree of risk due to the lack of risk assessments. EVIDENCE: Three case files were examined, one case file for a respite service user who had been admitted to the home over a month ago only had a preadmission assessment in place which identified basic information with regards to the service user. There was no care plan, risk assessment or reviews in place to demonstrate that this service user had had any input during their stay at the home. The other two files observed demonstrated that service users undergo various assessments such as manual handling, nutrition, continence, infection and the activities of daily living which underpin the plan of care. Care plans in place were computer generated for core needs and individualised accordingly. Handwritten and personalised plans were available for more complex needs. Reviews between the case files were not consistent, within one file the reviews that had taken place were service user focussed and reflected care and condition, whereas the other was not despite evidence to demonstrate that Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 10 significant changes had occurred. Appropriate risk assessments were in place with the exception of one with regards to diabetes mellitus. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Service users receive a wholesome, appealing and balanced diet, however their safety may be compromised due to the lack of documentary evidence to demonstrate that appropriate cleaning is taking place. EVIDENCE: A four weekly menu is in place which demonstrated that a wholesome and appealing diet is on offer, choice is available and service users spoken with stated that food was nice, plentiful and at a good standard. Specialist diets are catered for and there was evidence that service users undergo nutritional assessments as part of their plan of care. The kitchen was observed to be clean and tidy however there was no documentary evidence to substantiated appropriate cleaning had taken place for the month of November. The cook stated that she checks all deliveries into the home to ensure it is satisfactory, however there was no documentary evidence to substantiate this. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Due to the lack of valid criminal record bureau check in place and the implications service users are placed at a degree of risk. EVIDENCE: Four trained staff members, six care staff and three domestic staff employed did not have a satisfactory criminal record bureau check in place. Both the manager and proprietor stated they were unaware that previous checks that had taken place with another company were not transferable and valid, thus anticipating only two staff members were with out checks; however these had been applied for. The inspector contacted the regulation manager who then contacted the commission for social care legal advisors. Following advice the inspector, manager and administrator contacted appropriate agencies and commenced the procedure of gaining protection of vulnerable adult checks, all staff were notified and staff on duty at the time of the inspection were replaced by staff who had a disclosure in place. A short term and long term action plan was put into place, the duty rota appropriately covered and a declaration and policy with regards to supervised practice implemented in preparation of the return of POVA 1st checks. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users live in a safe and satisfactory environment, however this may be compromised if requirements are not actioned appropriately. EVIDENCE: Routine maintenance is carried out as required and an annual development programme is in place. The environment was noted to be at a satisfactory standard with the exception of the small dining area where the carpet was noted to be badly stained and the wallpaper ripped. There are ample domestic staff employed to maintain the standard of cleanliness of the home and both service users and the relatives spoken with commented on this aspect. The environmental health officer visited the home in May of this year and set a requirement, this remains outstanding. The manager stated that the requirement set by the fire authority had been actioned which was the testing of emergency lighting, however in examination of these records these had not been carried out on a regular basis. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Despite sufficient staff being employed to meet service users needs, this is now compromised due to the restrictions place upon staff in regards to the criminal records bureau checks. Staff employed are working towards ensuring service users are in safe hands at all times, the national vocational qualification and induction programme will enhance this once completed. EVIDENCE: The staff rotas were observed and demonstrated sufficient staff are employed to meet service users needs, however following the immediate requirement set with regards to criminal records bureau checks four registered nurses and six care staff were unable to work until satisfactory protection of vulnerable adult checks are obtained, staff are then to work under appropriate supervision practices as discussed with the commission of social care inspection until satisfactory criminal record bureau checks are obtained. Ninety percent of staff have commenced working towards a national vocational qualification, however there are currently difficulties with the training company and assessor used and the staff are awaiting the appointee of a new assessor in the near future. The home has a brief induction package in place ensuring new staff are aware of health and safety issues and service users needs, the manager is proposing to research and introduce a recognised induction programme in the near future. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 Although attempts are made to ensure the home is run in the best interests of service users these attempts are not fully fulfilled thus concerns/suggestions are not appropriately dealt with and resolved. EVIDENCE: Questionnaires are used to ascertain feedback form service users and relatives on an annual basis, these were observed and responses were noted to be generally positive, however issues of concerns were also noted. The manager stated that she would action any negatives drawn to her attention through this method, however she stated she had not had the time to address these issues as yet. There are currently no service users meetings arranged, the manager stated this is an area she is looking towards improving and implementing in the near future. The manager stated that policies are reviewed annually or if there are any significant changes, however on observation many policies had not been reviewed for several years. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 16 With regards to service users personal allowances the procedure remains as previous and therefore the requirement remains outstanding. The fire log was examined, there was evidence of fire drills/tests taking place, however the fire alarm system had not been tested routinely on a weekly basis and the emergency lights had not been tested on a monthly basis. On checking the maintenance and certification for servicing only the gas certificate was readily available, the manager as she was also working on the floor was unable to dedicate the time to locate the clinical waste, electrical, fire, water testing and drug policy. A contact with regards to the disposal of medicines has also yet to be arranged. Staff training continues to develop in mandatory areas. Eleven staff had invalid criminal records bureau checks in place and two staff were waiting return of criminal records bureau checks. The requirement set at the previous inspection with regards to ensuring service users have a means of contacting staff at all times has not been action, service users who sit in the smaller lounge/dining room do not had a call bell close at hand. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 1 Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 18 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 15(2b) Requirement Service users reviews are required to reflect care received and individual outcomes. This has been partly met, however further development is required. Service users care plans must accurately reflect how identified individual needs will be met. this is an outstanding requirement and must be addressed to avoid enforcement action. Risk assessments are required to demonstrate how an identified risk will be managed. This is an outstanding requirement and must be addressed to avoid enforcement action. The medication policy requires updating to include keeping medication for seven days following a service users death. Adequate procedures are required to be in place to ensure the safe storage and disposal of medication. This is an outstanding requirement from April 2005 and must be addressed to avoid enforcement action. DS0000026407.V262015.R01.S.doc Timescale for action 13/12/05 2. OP7 15 (1) 17/11/05 3. OP7 13(4c) 17/11/05 4. OP9 13(2) 17/11/05 Alexandra House Care Home Version 5.0 Page 19 5. OP12 16(n) 6. OP14 12(2,3) 7 OP15 12(a) 8. OP18 19(b) Sch 2 13(6) 9 10. OP19 OP27 23 (2,b,d) 18(1a) 11. OP35 12(2) Further consideration is required to ensure the routines of the home are flexible and activities are varied to meet service users expressed needs. This is an outstanding requirement and must be addressed to avoid enforcement action. Further consideration is required to ensure service users have choice and control over their lives. It is required that there is a means of communicating with staff in each room service users have access to. This is an outstanding requirement and needs to be addressed to avoid enforcement action. To ensure appropriate documentation is in place with regards to the kitchen cleaning and delivery checks to ensure service user safety. All staff are required to have satisfactory criminal records bureau checks in place. This is an outstanding requirement and must be addressed to avoid enforcement action. All staff with out a valid check in place must not work at the establishment until a satisfactory POVA 1st check has been attained, they must then remain under supervision until CRBS received. The carpet in the little lounge is in need of replacement. The décor also requires attention. Staffing levels are required to demonstrate that service users needs can be fully met. This is an outstanding requirement and must be addressed to avoid enforcement action. Service users are required to have access to personal allowances without restrictions imposed. This is an outstanding DS0000026407.V262015.R01.S.doc 17/11/05 17/11/05 17/12/05 17/11/05 17/01/06 17/11/05 17/11/05 Alexandra House Care Home Version 5.0 Page 20 12 OP37 17 13 OP38 23(4,a,c) 14 OP38 23(2,b,c,n ,o) requirement and must be addressed to avoid enforcement action. To ensure all policies and procedures are reviewed annually or as changes occur to ensure up to date practices are maintained. After consultation with the fire authority take adequate precautions against the risk of fire. To provide evidence of maintenance certificates to demonstrate that all servicing is up to date and complies with legislation. 17/01/06 17/12/05 17/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations To readily act upon any concerns/suggestions brought to attention via the quality assurance monitoring. Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexandra House Care Home DS0000026407.V262015.R01.S.doc Version 5.0 Page 22 - 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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