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Inspection on 06/07/06 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 6th July 2006.

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 ethos was prevalent throughout the home. Service users spoken with spoke highly of the staff and care received, stating they were respectful and listened to their needs. Staff spoken with were able to discuss the core values and principles and service users needs to a good standard.

What has improved since the last inspection?

Care plans have developed further to ensure they are more personalised ensuring service users personal choices and preferences are taken in to account. The majority of staff now have satisfactory criminal record bureau checks in place ensuring service users are further protected. A new acting manager is now in employment working towards ensuring the home is run and managed by a person fit to be in charge.

What the care home could do better:

It is acknowledged that the home has experienced difficulties with regards to the management of the home due to the departure of the previous manger and the time it has taken to employ a new acting manager, however there are requirements that must be addressed to ensure the home complies with the Care Standards Act 2000 and the National Minimum Standards. It is recommended that care plans are further developed to reflect equality and diversity of individuals to ensure whole person needs are fully met. 50% of staff are trained at the National Vocational Qualification level 2 and the induction programme is further developed to ensure service users are in safe hands at all times. To further develop the quality assurance systems in place to substantiate that the home is run in the best interests of service users. To provide evidence of the electrical maintenance certificate to demonstrate that all servicing is up to date and service users are protected. The following are requirements: Service users reviews are required to reflect care received and individual outcomes to ensure needs are fully met. Service users care plans must accurately reflect how complex needs will be met to ensure service users needs are fully met and service users are protected. Risk assessments are required to demonstrate how an identified risk will be managed to ensure service users are protected. The responsible individual is to ensure the safe receipt; administration, recording and disposal of medication to ensure service users are fully protected. Further consideration is required to ensure the routines of the home are flexible and activities are varied to meet service users expressed needs.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. To liaise with the environmental health officer to ensure appropriate documentation is in place with regards to the kitchen cleaning and delivery checks to ensure service user safety. Staff who are working only with POVA 1st checks in place must have two satisfactory references in place and must work under supervision to ensure service users are protected. A redecoration programme is required to be forwarded to the commission to identify when work is to commence to demonstrate that service users live in a well-maintained environment. Appropriate equipment to ensure service users are fully protected whilst using bedrails is required to be provided to ensure service users are fully protected. An audit of service users dependency levels is required to demonstrate that adequate staff are in place to fully meet service users needs. All staff employed are required to have documentation on file as listed in schedule 2 to ensure service users are protected. Staff are required to be trained in all mandatory areas in order to demonstrate they are knowledgeable and competent in their job role. 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. To ensure all policies and procedures are reviewed annually or as changes occur to ensure up to date practices are maintained. Further consultation with the fire authority is required to ensure adequate precautions are taken against the risk of fire. Evidence is required to demonstrate that water temperatures are risk assessed to ensure service users are fully protected.

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 6th July 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 DS0000026407.V302757.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.V302757.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 Jacqueline Ann Colson-Osborne 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.V302757.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 17th November 2005 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.V302757.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 thus 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 three 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. Five service users were spoken with, one relative and one visiting professional so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The nurse in charge and the administrator 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. A new acting manager has commenced employment, unfortunately she was not available during the visit as she had worked the previous night, however the inspector did hold a conversation with her over the telephone. What the service does well: A kind and caring ethos was prevalent throughout the home. Service users spoken with spoke highly of the staff and care received, stating they were respectful and listened to their needs. Staff spoken with were able to discuss the core values and principles and service users needs to a good standard. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is acknowledged that the home has experienced difficulties with regards to the management of the home due to the departure of the previous manger and the time it has taken to employ a new acting manager, however there are requirements that must be addressed to ensure the home complies with the Care Standards Act 2000 and the National Minimum Standards. It is recommended that care plans are further developed to reflect equality and diversity of individuals to ensure whole person needs are fully met. 50 of staff are trained at the National Vocational Qualification level 2 and the induction programme is further developed to ensure service users are in safe hands at all times. To further develop the quality assurance systems in place to substantiate that the home is run in the best interests of service users. To provide evidence of the electrical maintenance certificate to demonstrate that all servicing is up to date and service users are protected. The following are requirements: Service users reviews are required to reflect care received and individual outcomes to ensure needs are fully met. Service users care plans must accurately reflect how complex needs will be met to ensure service users needs are fully met and service users are protected. Risk assessments are required to demonstrate how an identified risk will be managed to ensure service users are protected. The responsible individual is to ensure the safe receipt; administration, recording and disposal of medication to ensure service users are fully protected. Further consideration is required to ensure the routines of the home are flexible and activities are varied to meet service users expressed needs. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 7 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. To liaise with the environmental health officer to ensure appropriate documentation is in place with regards to the kitchen cleaning and delivery checks to ensure service user safety. Staff who are working only with POVA 1st checks in place must have two satisfactory references in place and must work under supervision to ensure service users are protected. A redecoration programme is required to be forwarded to the commission to identify when work is to commence to demonstrate that service users live in a well-maintained environment. Appropriate equipment to ensure service users are fully protected whilst using bedrails is required to be provided to ensure service users are fully protected. An audit of service users dependency levels is required to demonstrate that adequate staff are in place to fully meet service users needs. All staff employed are required to have documentation on file as listed in schedule 2 to ensure service users are protected. Staff are required to be trained in all mandatory areas in order to demonstrate they are knowledgeable and competent in their job role. 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. To ensure all policies and procedures are reviewed annually or as changes occur to ensure up to date practices are maintained. Further consultation with the fire authority is required to ensure adequate precautions are taken against the risk of fire. Evidence is required to demonstrate that water temperatures are risk assessed to ensure service users are fully protected. 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.V302757.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.V302757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to admission. EVIDENCE: Service users are visited in the community and a preadmission assessment is carried out prior to admission. Service users and relevant others may also visit the home. The preadmission assessment covers the requirements of the standard and there was evidence to substantiate that these take place within service users files. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 10 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 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in a plan of care, however needs may not be fully met as complex issues may not be identified. Reviews taking place in the main were not service user focussed thus not fully reflecting service users current care and condition despite a requirement being set at the previous inspection that service users reviews are required to reflect care received and individual outcomes. It is recommended that care plans are further developed to ensure equality and diversity of service users is fully recognised and enhanced. Service users may be placed at a degree of risk due to the lack of management plans in regards to risk assessments. Service users health care needs are met. Service users are not fully protected by the homes medication policies and procedures. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 11 Service users undergo various assessments with regards to the activities of daily living, manual handling, infection and nutrition, information gained forms the basis of the plan of care. Care plans in place have develop since the previous inspection and are more personalised, however within one file examined where a service user was highlighted as having diabetes a plan of care or risk assessment were not in place and another where the service user had been identified as having methacillin resistant staphylococcus areus there was a risk assessment in place but no care plan. Of two case files examined bedrails were in use, there was no consent forms to demonstrate this had been gained. There was a risk assessment in one file but not in the other for the risk of entrapment. Accident records demonstrated that service users have in the past sustained injury from bedrails; on speaking with staff it would appear there is insufficient equipment available for all service users who require bumpers to protect them from entrapment. Despite a requirement being set at the previous inspection and an action plan returned to the Commission for Social Care Inspection stating that risk assessments are carried out there was little evidence of management plans as to how the risks were being managed or reduced. Daily records were maintained and contained information with regards to significant events. Reviews also take place, however in the main these were not service user focussed to fully reflect service users current care and condition. Service users spoken with stated that their needs were met and they were settled. Staff spoken with were able to discuss service users needs and the core values and principles. There was evidence to demonstrate that specialist services and equipment is accessed as required. One service user spoken with stated they may see the doctor at any time. Relevant medication polices are in place however on examining medication against those service users case tracked medication charts there was evidence to demonstrate that there were gaps in signing for medication administered; in one case medication had not been administered; hand written entries were not signed to demonstrate these were correct and despite the nurse in charge stating that medication was checked into the building on the medication charts there was no evidence to demonstrate this. The home has recently had a pharmacy inspection by their suppliers, several areas for improvement were identified, and there was evidence to demonstrate that an action plan had been devised to address these issues. Staff are instructed on maintaining service users privacy and dignity and they were able to discuss these issues. Service users spoken with stated that staff were respectful and their privacy was maintained. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 12 Alexandra House Care Home DS0000026407.V302757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users find the lifestyle experienced in the home meets their expectations and satisfies their needs in the main; however there were some service users who felt this could be improved upon. This is to be addressed as a requirement set at the previous inspection highlighted this and the action plan returned to the Commission for Social Care Inspection stated that staff were carrying out activities. However it would appear from discussion held with staff and service users that there is little time available to do this. Service users are enabled to maintained contact with relevant others as they wish. Service users are helped to exercise choice and control over their lives, however it would be of benefit for service users if issues with regards to ensuring equality and diversity of individuals is enhanced. Further consideration is still required to ensure service users have choice and control over their lives. Service users receive a wholesome and appealing diet in pleasing surroundings, however minor improvements in documentation are still required to ensure service users are fully protected. EVIDENCE: Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 14 There is no activities coordinator in post at present, if the workload allows staff spend time with service users. Outside entertainment is also provided on occasion. On speaking with service users the response in regards to activities was that some are content with that on offer whereas others wished there was more to do, as they were bored. Some service users entertain themselves playing dominoes if able. A church service is also held in the home should service users wish to attend. Staff stated that the routine of the home is flexible and service users may choose how they spend the day, service users spoken with substantiated this. There are no restraints 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. In respect of equality and diversity of service users staff were able to discuss the basic issues in regards to how this is embedded into the ethos of the home, care plans have developed in the sense they are now more personalised, however there is limited information in the respect of how equality and diversity will be facilitated in regards to each individual. The provider stated that plans were in place to fit a new buzzer in the small lounge, however this is still to be completed. A choice is offered at meal times, which service users substantiated. Service users spoken with stated meals were at 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 takes place as appropriate were available, however there were no records to demonstrate that items are checked on delivery to the home despite the cook stating this occurs. The cleaning rota in place showed gaps in the cleaning plan, the cook stated this was due to the frequency that things were due to be cleaned. A requirement was set in respect of this at the previous inspection and an action plan was received from the provider stating this had been actioned, however there was no evidence available to demonstrate this. Alexandra House Care Home DS0000026407.V302757.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users and relevant others may be assured their complaints will be listened to taken seriously and acted upon. Service users safety may be compromised due to the lack of training in adult protection and up to date policies in place with regards to restraint. EVIDENCE: An adequate complaints procedure is in place. There have been no complaints received since the previous inspection. Service users spoken with express no complaints with care received. All staff with the exception of two new starters have current criminal record bureau checks in place; the two new members of staff have undergone POVA 1st checks, however two references have not been received for these members of staff. There were no records available to demonstrate that staff had received training in adult protection, however on specking with staff they were able to discuss the relevant issues with the inspector. The policy with regards to restraint has not been reviewed since 1999, there was evidence of accidents taking place when restraints have been used, issues with regards reducing these incidents were not within the policy and appropriate risk assessments were not available in all case files examined. Alexandra House Care Home DS0000026407.V302757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users live in a moderately safe but in some areas poorly maintained environment in regards to décor, which is ripped in places giving a poor impression. The home is clean and hygienic. EVIDENCE: A maintenance book was observed to be in place and maintenance is carried as required. Some areas of the home are now in need of redecoration, the administrator stated there were plans to address this in the near future. Appropriate equipment was noted to be in place, however it was apparent that bedrails and associated equipment needs attention, as incidents of entrapment had occurs and staff reported that there was a lack of bumpers for bedrails and one pair in use had been reported as broken however was still in use. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 17 The gardens were satisfactorily maintained. The laundry room was clean and tidy and appropriate equipment in place. The home was clean and tidy and free from offensive odour. Alexandra House Care Home DS0000026407.V302757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality rating for this outcome area is adeqaute this judgement was made using evidence available including a visit to the service. Service users needs are met by the number and skill mix of staff however further consideration is required in respect to the dependency of service users to ensure staff are fully able to meet needs to a good standard. Staff are working towards ensuring service users are in safe hands at all time, however improvements in regards to the induction programme is required. Service users are not fully supported and protected by the homes recruitment policies and practices. Staff are not fully trained in all mandatory areas thus deficits in care received may occur. EVIDENCE: Staff rotas were observed which demonstrated that sufficient staff for the number of service users are employed, however on speaking with staff it was stated that some service users are of a high dependency and it was felt this was not fully recognised in the staff allocation. On speaking with service users no specific concerns with regards to the staffing levels were expressed, however comments were made that staff are extremely busy at all times and there was not really enough staff. Four members of staff have attained the national vocational qualification level 2 and six are working towards this qualification. The induction programme remains brief and does not cover a number of required issues. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 19 Four staff personal files were observed, not all had the required documentation on file as listed in schedule two. Staff training records demonstrated that there are large deficits in mandatory training. The administrator stated there were plans to address manual handling training and health and safety. One member of staff spoken with felt there was sufficient training whereas another felt more was necessary. Service users spoken with stated that staff were kind and caring and were respectful at all times. Alexandra House Care Home DS0000026407.V302757.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality rating for this outcome area is poor this judgement was made using evidence available including a visit to the service. The home is run and managed by a person who is of good character and who is dedicated to providing a quality service, she now needs to apply to become the registered manager to ensure the home is run by a person who is fit to be in charge. There is evidence available to demonstrate that the home is aiming to run in the best interests of service users, however minor improvements are required to fully meet this standard. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff is compromised due to the various issues as noted in the evidence gained during the visit. EVIDENCE: Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 21 A new acting manager commenced employment May 2006. She has previous managerial experience and has completed the registered managers award. She stated she feels very happy in her new role and is at present settling in and getting to know staff and service users. She has held a staff meeting and residents/relatives meeting in order to introduce herself. There are issues she will be looking to develop within the home in the future. Staff spoken with stated that the acting manager was supportive and approachable. Service users spoken with expressed no concerns with regards to the management of the home. Quality assurance questionnaires were last carried out in April of the previous year, these have not been done since. Results of the questionnaire were collated and areas addressed as required. The provider does not send monthly regulation 26 forms to the Commission for Social Care Inspection. A requirement was set at the previous inspection with regards to ensuring policies and procedures are reviewed annually or as needed, an action plan received stated this is done, however policies and procedures within the home do not reflect this due to the dates on them and also the restraints policy does not cover all that is required. The home does not deal with service users personal finances with the exception of the payment of hair dressing fees where a small amount of money is kept in an account for this service. Appropriate records were available to demonstrate the safekeeping of this. At the previous inspection there were also concerns in regards to the testing of the fire systems and staff training in fire drills, despite an action plan stating that the home is in regular consultation with the fire authority being sent to the Commission for Social Care Inspection there still remains deficits in this area. There were no water temperatures available to demonstrate that regular checks have been taken. Appropriate maintenance certificates were available with the exception of the mains electric. There was a lack of appropriate risk assessments in place as discussed in standard 7. There is a lack of associated equipment in regards to the use of bedrails as discussed in standard 7. Not all documents as required in schedule 2 were available in staff files. Staff training lacks in mandatory areas. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 22 Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 23 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 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X 2 1 Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 24 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 still required. Service users care plans must accurately reflect how complex needs will be met. 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 responsible individual is to ensure the safe receipt; administration, recording and disposal of medication to ensure service users are fully protected. 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 DS0000026407.V302757.R01.S.doc Timescale for action 06/08/06 2. OP7 15 (1) 06/10/06 3. OP7 13(4c) 06/08/06 4. OP9 13(2) 20/07/06 5. OP12 16(n) 06/08/06 Alexandra House Care Home Version 5.2 Page 25 outstanding requirement and must be addressed to avoid enforcement action. 6 OP14 12(2,3) 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 liaise with the environmental health officer to ensure appropriate documentation is in place with regards to the kitchen cleaning and delivery checks to ensure service user safety. Staff who are working only with POVA 1st checks in place must have two satisfactory references in place and must work under supervision. A redecoration programme is required to be forwarded to the commission to identify when work is to commence. Appropriate equipment to ensure service users are fully protected whilst using bedrails is required to be provided. An audit of service users dependency levels is required to demonstrate that adequate staff are in place to fully meet service users needs. All staff employed are required to have documentation on file as listed in schedule 2 to ensure service users are protected. Staff are required to be trained in all mandatory areas in order to demonstrate they are knowledgeable and competent in their job role. DS0000026407.V302757.R01.S.doc 06/08/07 7 OP15 12(a) 06/08/06 8 OP18 19(b) Sch 2 13(6) 14/07/06 9 OP19 23(2,b) 20/08/06 10 OP19 13(4,c) 14/07/07 11 OP27 18(1a) 06/08/06 12 OP29 19(1,b) 06/08/06 13 OP30 18(1,c) 06/10/06 Alexandra House Care Home Version 5.2 Page 26 14 OP31 8(1) 15 OP37 17 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. Ensure all policies and procedures are reviewed annually or as changes occur to ensure up to date practices are maintained. Further consultation with the fire authority is required to ensure adequate precautions are taken against the risk of fire. Evidence of risk assessments in regards to demonstrating that water temperatures are safe is required to ensure service users are fully protected. 06/09/06 06/08/06 16 OP38 23(4,a,c) 06/08/06 17 OP38 13(4,c) 06/08/06 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 OP14 OP28 OP33 OP38 Good Practice Recommendations Develop care plans to reflect equality and diversity of individuals. 50 of staff are trained at the National Vocational Qualification level 2. The induction programme is further developed. To further develop the quality assurance systems in place. To provide evidence of the electrical maintenance certificate to demonstrate that all servicing is up to date. Alexandra House Care Home DS0000026407.V302757.R01.S.doc Version 5.2 Page 27 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.V302757.R01.S.doc Version 5.2 Page 28 - 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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