CARE HOMES FOR OLDER PEOPLE
Alexandra House Care Home 23 Euston Road Gt Yarmouth Norfolk NR30 1DZ Lead Inspector
Ginette Amis Unannounced Inspection 3rd May 2006 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 DS0000015609.V293396.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 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 DS0000015609.V293396.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Alexandra House Care Home Address 23 Euston Road Gt Yarmouth Norfolk NR30 1DZ 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) 01493 859641 01493 859707 Mrs. Pru Garvan Mr. R Sidney Shunmuganathan Nallathamby Care Home 25 Category(ies) of Dementia (25) registration, with number of places Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Twenty-five (25) Older People who suffer from Dementia may be accommodated. 5th September 2005 Date of last inspection Brief Description of the Service: Alexandra House is a care home with nursing providing accommodation and care for up to 25 older people with dementia. The home is situated within Great Yarmouth, close to the town centre and seafront. The accommodation is on four floors with nine single and eight shared rooms, some have en-suite facilities. The communal rooms consist of three lounges and one dining room. A small garden and patio surround the building, with car parking at the rear. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 10 am and 5pm on Wednesday 3rd May 2006. Both the registered proprietors of the care home, the registered manager and team leader together with other members of the staff team helped to provide information that has assisted with the compilation of this report. All but one of the 23 residents of Alexandra House were met with during the day. Members of the care staff team were spoken with as they went about their duties, as were domestic staff, the cook in charge and her assistant, all of whom were courteous and helpful. A second hour-long visit was made to Alexandra House at 3.30pm on Wednesday 10th of May for the purpose of meeting with the deputy manager who takes responsibility for staff training and appraisals. On the morning of 3rd May, a conducted tour was made of the premises. During the afternoon the opportunity was taken to independently move about the care home, initiated conversation with all of the residents met with. However, only one resident was able to give an informed view about the care home. Three relatives of residents were met with in private and able to give their opinions of the care home. A friend of a resident visiting at the time was also spoke with and turned out to be a retired member of staff who wished to keep up contact with residents she had formerly cared for. Another relative offered his comments on the care home by telephone on the 4th May. In addition 13 family members completed service user comment cards on behalf of residents and sent to them to CSCI. Two local General Practitioner working with the care home also returned a comment card. All of the comments received in this way presented a positive view of the care home and included several affirmations as to the high quality of the care. The care home’s manager completed a pre inspection questionnaire about the numbers of residents and staff at the care home along with other practical data. Alexandra House is a long established care home with nursing that specialises in caring for people with dementia. Residents were initially referred to the care home by the health authority or local social services departments. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 6 What the service does well:
Alexandra House offers a good standard of care and comfort to all its residents. A qualified nurse with considerable experience in caring for people with dementia is the registered manager of the home. He is actively supported on a daily basis by the care home’s proprietors and registered providers, one having been involved in caring for people with dementia for the past 30 years. The second registered provider takes responsibility for the maintenance of the building. More than half the care team have been employed at Alexandra House for many years and form a loyal nucleus. It is customary for staff to always work in pairs, with a more experienced member of staff taking a junior or less experienced staff member under their wing. There are dedicated domestic staff and this ensures that care staff can concentrate their efforts on meeting resident’s needs. All those members of staff spoken with and observed were found to be pleasant and appeared thoughtful, respectful and caring towards residents. The proprietors and management team have strong views concerning respect for individuals and it is a rule of the house that members of staff address residents by their title and surname. All residents’ needs are assessed prior to admission. Care plans are subsequently devised then regularly reviewed by senior staff. Residents’ relatives or representatives are, whenever possible, closely involved in this process. A period property retaining many of its original features, the care home was once an hotel. Its’ rooms are spacious with large windows from some of which the sea front can be glimpsed. Most rooms have a pleasant outlook. The lounges are attractively decorated, providing comfortable communal spaces, one of which serves as a quiet room. The property is large and while not in every respect suitable for its purpose has been well maintained over the years, is accessible, safe and pleasant to be in. It is observable how the proprietors have taken residents’ needs and comfort into account. In particular, as the result of a comprehensive regime undertaken by domestic staff, the care home is exceptionally clean with all bedding changed on a daily basis. The care home offers regular sessions of activities or pastimes for residents and there are periodic outings. As on the previous inspection, the food was highly praised by residents and by their relatives. One relative said he welcomed the opportunity to comment on the care home, praising its management and staff and stated he found it impossible to fault the service. A second couple, who were visiting a relative who had been resident at Alexandra House for many years shared this view. A forth relative, spoken with by telephone, also felt that the quality of care offered was very high, and described managers and staff as warm, friendly, capable and helpful. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better:
Two requirements were made. The first concerns the need for at least 50 of the staff team to gain NVQ accreditation. The manager must plan to encourage this. The second relates to the need for a formal quality assurance system to be put in place. While the care home does seek to find out the views of residents and their relatives, and has established annual appraisals for staff, the findings of any investigations are never quantified or assessed or acted on in a way that is measurable. Similarly general plans for the care home have not been produced in a way that can be evaluated or linked to time scale. A recommendation was made urging the proprietors that as they planned for the future of the care home, for any developments they might wish to make to the service, it should be held in mind how double rooms are undesirable as private accommodation for residents. This was felt to be particularly the case for people suffering from dementia who, by consequence of their problems in communication might be unable to voice a view. It was stressed this recommendation should be regarded as a serious matter. Another recommendation attached to the system of staff supervision. While members of staff do receive periodic supervision, when the deputy manager accompanies them on their shift, this was not being formally recorded and a record needed to be maintained. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 8 The care home has a competent manager but one who concentrates the majority of his time on ensuring that residents’ health and personal care needs are met. A recommendation for him to be super-numerary at least 2 days per week was made at the last inspection to enable him to concentrate on managerial tasks. It would appear that both he and the provider have resisted this as both are happy with present arrangements. The provider currently assumes a managerial role on non-caring activities on a daily basis. The deputy manager concentrates on staff training, appraisal and supervision as well as offering a stress counselling service. It was recommended a review of these arrangements should take place and an agreement be reached between all parties over the formal division of the work load and this, together with the rational for how much time the registered manager will be devoting to managerial tasks included in the action plan the care home returns in response to this report. Finally, it was discovered that while the care home does have a computer this has not been linked to the internet. A recommendation was made for the care home to acquire an e-mail address. 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 DS0000015609.V293396.R01.S.doc Version 5.1 Page 9 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 DS0000015609.V293396.R01.S.doc Version 5.1 Page 10 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): 1,3 and 6 Quality in this outcome area is good. Prospective residents and their relatives or representatives are routinely offered useful information about the care home to help them to decide on admission there and residents have the opportunity to visit the care home to aid the decision making process. Residents’ needs are fully assessed prior to admission and this would equally apply on the rare occasions that a short stay is requested. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 11 EVIDENCE: Previous inspection investigation had revealed that prospective residents and their relatives or representatives were given information about the care home to enable them to make an informed choice over admission and that residents were routinely offered the opportunity to visit the care home and spend sufficient time there in which to familiarise themselves with the building and daily routines, meet with members of staff and other residents. The hypothesis drawn from the above evidence that the situation would remain unchanged and that prospective residents would continue to receive useful information about the care home prior to admission was upheld. The relatives of the two residents to have been admitted to Alexandra House this year confirmed this to be the case. Examination of the files of 4 residents, including the above mentioned most recent admissions showed that an assessment as to the needs of prospective residents was made in advance of any agreement being reached over admission. This would apply should the care home be asked to accept a resident for a short stay. The manager and provider stated that it was however very rare for short stay accommodation to be agreed upon. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 12 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, 8, 9,10 Quality in this outcome area is good. The health and personal care of residents was safeguarded by the practices adopted by the care home. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 13 EVIDENCE: The findings of the previous inspection of last September, showing how trained staff work with residents and their relatives to compile an appropriate care plan, were repeated. The 3 residents’ relatives spoken with confirmed how they had been asked to contribute information and help agree a suitable plan for how best care should be offered. Comments made included “We’re always included” and “We were asked our views and to help agree how mother should be cared for”. The four care plans examined had each been signed by a family member or by the resident themselves. In addition the manager and deputy regularly reviewed the content of each care plan and relatives confirmed how when ever changes had to be made “We’re kept informed all the time” Comments made by pre-inspection questionnaire by two local General Practitioners indicated there to be no known concerns over the way residents are cared for and their health safeguarded. This view was endorsed in each of the 13 comment cards returned on behalf of residents (completed by their relatives) and those relatives spoken with during the course of this inspection. All spoke very highly of the care offered by the home. Three of the residents whose relatives offered comments on the care home described how they had witnessed a marked improvement in the health and general well being of their relative since they came to live in the care home. One resident who had been admitted to Alexandra House from a hospital was described by her relative as “not expected to make it….(and) all skin and bone and just wasting away” but was now “fit and well and making good progress and has put on weight”. None of the residents at the care home had pressure sores at the time of this inspection but members of staff related how some of their residents had been admitted to them with pressure sores but through attention to their care the problems had been overcome. The care home had invested in a number of mattresses designed to relieve pressure area problems. It was observed how all the residents appeared clean and tidy and were neatly dressed. The provider stated how all were offered a bath or shower on a daily basis. As found at the previous inspection, medication continued to be appropriately stored and administered. Nursing staff alone took responsibility for medication. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 14 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): 12,13,14 and 15 Quality in this outcome area is good. The care home makes a concerted effort to meet the recreational needs of its residents and to ensure that daily life is pleasantly spent. The standard of the meals supplied was very good and dietary needs well documented and good diet had contributed to health improvements for some residents. EVIDENCE: As was found at the previous inspection, residents are daily offered activities to take part in should they wish. While the range of the activities observed on the day of this inspection was confined to completing puzzles, drawing and assembling Lego, staff were observed to interact one to one in turn with those residents taking part in an amiable and patient manner. It was evident from observation and conversation with different residents how many of the people living at the care home were unable as result of their advanced dementia to make an informed choice about the type of activities or pass times that might best engage their interest. The work begun some months ago in collecting life history information about each resident, as an aid to staff catering for their interests was being continued. However, one resident spoke of a trip to a local theatre that was being planned by the provider. Another resident described with enthusiasm how she organised a sweep-stake once a week for residents and members of staff to enjoy.
Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 15 From the relatives visiting the care home on the day of the inspection and comments made by others, either in the pre inspection comment cards or as previously invited to by the provider (in a section of the residents’ file devoted to giving their friends and relatives an opportunity to comment on the care home) it was apparent how visitors were made to feel welcome and at home. The provider offered an account of how the home had dealt with an issue raised as a result of one resident having a minority religious faith. At the previous inspection, meals at the care home were rated to be of high quality. From observation and the comments passed by residents and their relatives there was no reason to suggest that standard had not been maintained. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 16 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): 16 18 Quality in this outcome area is good. Residents are protected by the care home’s policies and procedures and the training staff are given to raise their awareness as to possibilities for vulnerable adults being abused and the need to safeguard against this. EVIDENCE: The care home has a complaints procedure in place. No complaints have been made against the care home in the past 12 months. All members of the staff team, including the 2 providers had received training to make them aware of the need to protect their residents from any form of abuse. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 17 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): 19,21,24 and 26 The quality outcome for this area is adequate. The care home is safe and generally comfortable while kept exceptionally clean and tidy. Planned programmes of redecoration and renewal are diligently executed. Bathrooms due for redecoration should be made more comfortable and user friendly with some equipment renewed. The providers should formulate plans for the future of the care home that take account that sharing bedrooms is no longer considered an acceptable option. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 18 EVIDENCE: At the previous inspection the care home was found to be clean and tidy and generally well maintained. Since then, some further redecoration and window replacements have been completed. Plans were in progress to redecorate the dining room and as could be expected in a property of such considerable size and age, to continue with regular maintenance and renewal as necessary. The communal lounge areas were found to be particularly comfortable, attractively decorated and pleasant to sit in. The standards of decoration in residents’ bedrooms was also good and though in some cases, articles of furniture might appear a little worn it was evident how efforts had been made to personalise rooms and make residents feel comfortable and at home. Those rooms that were shared were seen to be particularly spacious and each had been divided by a curtain. While the providers relate how they have always taken pains to insist persons asked to share do so with their agreement (or the agreement of their relatives) with efforts made to ensure compatibility between those who share, both are aware how, for the future, shared accommodation is unlikely to be viewed as desirable and for this reason a recommendation has been made for very careful consideration to be given to the draw back of operating a care home with such a high number of shared bedrooms. While the care home has an adequate number of bathrooms and toilets, and some bedrooms have en suite facilities it was felt that the bathrooms were unnecessarily austere and in some areas equipment was in need of attention. As plans to redecorate bathrooms were already in hand a recommendation was made for these areas to be made more comfortable and attractive. All radiators have been covered and the water supply governed to safe temperatures and subject to tests for Legionella. The Environmental Health officer last visited the care home on 28/03/05 when everything was found to be satisfactory. The fire officer inspected the care home last in 05 and visited 28/03/06 to inspect the newly installed fire panel. Again all was found to be satisfactory. The care home has 2 shaft lifts but one of these was out of use as result of a contractor failing to complete an undertaking to supply a replacement. An alternative contractor was being sought so that this work could be progressed as soon as possible. The providers are aware of the need to follow this through to conclusion. While there are 2 staircases it would not be possible for many of the residents to make use of these in the unfortunate event of the second lift becoming out of order. Each staircase remains open but is ‘guarded’ by a magic eye beam that would alert staff during those periods when residents are upstairs. There was an out door fire escape. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 19 As was found at the previous announced inspection, on the day of this unannounced inspection the entire care home was found to be commendably clean. Dedicated cleaning staff were met with and observed going about their rigorous duties, which entailed every room in the house being thoroughly cleaned on a daily basis with all bedding changed daily. The laundress was spoken with and it was seen how great attention was also paid to ensuring the care of residents’ clothing. In all respects it was apparent how the care home takes cleanliness and matters related to infection control very seriously. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 20 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): 27,28, 29 and 30 The quality outcome for this area is adequate. Residents benefit from the care home being staffed by a generally stable, well organised and conscientious team. Although a registered manager was in post, the providers remain dedicated to overseeing life within the care home on a daily basis. EVIDENCE: Copies of the staff rotas were supplied and from these and observation on the day of this unannounced inspection it was apparent how there are generally sufficient staff deployed within the care home to ensure residents needs will be met. In particular, domestic duties were well organised around a dedicated team so that members of the care team were not detracted from the care needs of residents. A member of the nursing team takes responsibility for carers on duty, day or night. Overall responsibility for residents’ welfare is assumed by the registered manager, his deputy and the care team leader, with the care home’s owners on hand daily to offer their support. The file of one new member of staff was seen to contain documentation to suggest that the findings of previous inspections as to the appropriateness of recruitment procedures remains unchanged. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 21 At present less than half the care team have NVQ accreditation. A recommendation made at the previous inspection for this problem to be addressed had not lead to any real change in the situation. The management must develop a strategy to encourage staff to undertake the accreditation. While the deputy manager works to ensure appropriate training is offered staff, conducts annual appraisals (that are documented) and periodic supervision sessions, the latter were not documented. A recommendation was made for staff supervision, conducted at least 6 times per year, to be formally recorded. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 22 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): 31,32,33,35,36 and 38 The providers and management team take joint responsibility for ensuring residents needs are met, and their general well being and health and safety protected. A documented, measurable quality assurance system must be put in place. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 23 EVIDENCE: The providers have offered care to people with dementia for a substantial number of years and despite having appointed a manager remain in regular day to day contact and charge of the home. Their input is considerable and as a result, their expectations of the manager are confined to the direct welfare of residents. It was recommended that the situation is made explicit within a mutually agreed managers’ job-description. The situation should be reviewed and the outcome outlined in the action plan the care home returns to CSCI in response to this report. This would help to inform an assessment of how the manager’s time should be divided between managerial and care duties. The registered manager is a qualified mental health nurse and has longstanding experience of working with people who have dementia. Other senior members of the staff team were also suitably experienced and from observation appeared very closely involved in delivery of service to the residents. Although the care home has taken steps to solicit comments on the care they provide, by encouraging relatives to write their feedback in a section of their relative - (the resident’s) care plan and regularly seeks to gain impressions from all involved, a system of quality assurance remains to be formalised as soon as possible. The quality assurance system must pay regard to long term aims, objectives in the form of short and medium term plans as well as documenting feedback from service users and their relatives or representatives and qualifying the implications of that feedback for the future of the care home. Fire fighting procedures and records of equipment servicing and staff drills showed that the care home continues to pay regard to matters of health and safety. Registration and Insurance certificates continue to be displayed in the main foyer. In the absence of family to do so, the provider oversees the weekly administration of one resident’s personal allowance from that resident’s bank account. Records are kept of each transaction entered into. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 24 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 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X 2 X 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 3 Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No 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. 2 Standard OP33 OP28 Regulation 35 18 (1)c Requirement A formal quality assurance system must be introduced The providers must find a way of encouraging at least 50 of their care team to gain NVQ accreditation Timescale for action 30/09/06 30/09/06 Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 26 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. 2 3 Refer to Standard OP21 OP36 OP24 OP31 Good Practice Recommendations Bathrooms should be made more comfortable and attractive. Staff supervision should be formally recorded. When formulating their plans for the future of the care home the providers should take account how shared accommodation is no longer a viable option. The providers should clarify to their inspector to what extent they personally assume management of the care home and show how agreement over this has been reached between them and the registered manager:- then re assess how much time the manager should be allocating to managerial tasks rather than care supervision and agree this with CSCI. Alexandra House Care Home DS0000015609.V293396.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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