Inspection on 06/12/05 for Alexandra Nursing Home

This inspection was carried out on 6th December 2005.

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.

Other inspections for this house

Alexandra Nursing Home 23/06/08

Alexandra Nursing Home 16/01/08

Alexandra Nursing Home 05/07/07

Alexandra Nursing Home 04/07/06

Alexandra Nursing Home 11/03/05

Alexandra Nursing Home 19/05/04

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 Nursing Home 370 Wilsthorpe Road Long Eaton Nottingham NG10 4AA Lead Inspector Steve Smith Unannounced Inspection 6th December 2005 09:30 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 Nursing Home DS0000002132.V269299.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 Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alexandra Nursing Home Address 370 Wilsthorpe Road Long Eaton Nottingham NG10 4AA 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) 0115 946 2150 BUPA Care Homes (BNH) Limited Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 PD place. On a named basis for the person named in the notice of proposal letter. 2nd June 2005 Date of last inspection Brief Description of the Service: The Alexandra Nursing Home is a purpose built care home registered for 40 Residents. The Home is registered to provide care for Residents with nursing and personal care needs. The Home provides a modern and pleasant environment for Residents and the accommodation is provided across two floors. There is a passenger lift and staircase access to the first floor facilities. The Home has two spacious lounge/dining areas, one with access to an octagonal sun lounge/conservatory. There is a landscaped garden to the rear of premises, which is accessible to Residents. The majority of bedrooms are single occupancy, with three double bedrooms provided for Residents wishing to share. All bedrooms are equipped with ensuite facilities. All bedrooms are also fitted with TV points, smoke detection equipment and thermostatically controlled radiators. The Home has provision of separate assisted bath/shower facilities. There is a call system, which operates in all areas of the Home. The Home also has a dedicated hairdressing salon. Relatives and visitors can call to visit Residents at any time. Alexandra Nursing Home DS0000002132.V269299.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 in just over 3.5 hours. Discussion was held with the Manager, a number of records were examined, and all public areas of the Home were examined. What the service does well: What has improved since the last inspection? What they could do better: The Registered Providers need to complete the statement of purpose by providing details of the physical environment standards met by the Home. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 6 The Acting Manager needs to ensure that each Resident, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The Acting Manager needs to ensure that Residents’ records are not left unattended for any period of time. Records of meals provided to Residents must also be maintained. Appropriate locks need to be provided on all toilet and bathroom doors. All staffing records need to comply with Regulations 19 and Schedule 2 of the Care Homes Regulations 2001. The Acting Manager also needed to review the length of time staff worked in the Home each day, limiting this whenever possible to no more than 8 hours. The Acting Manager needed to obtain her qualification at NVQ level 4 in Management. All appropriate staffing needed to attend training in Infection Control. 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 Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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 Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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): Standard 1. The statement of purpose and Residents Guide were well completed, but did not provide Residents with all of the information necessary on the provision of services by the Home. EVIDENCE: These Standards were not inspected on this visit to the Home. However, the Acting Manager said that Home’s statement of purpose had not been completed by providing the physical environment standards met by the Home. She undertook to complete this by the time of the next inspection of the Home. Standard 6 does not apply to this Home. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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): Standards 7 & 8. Records were maintained of Residents heath care, which ensured that Residents were appropriately looked after. EVIDENCE: At the time of the last inspection, the then Manager was required to ensure that each Resident, or their representative, had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. However, the now Acting Manager said that this issue had not been addressed, but she undertook to do so as each Resident fell due for a formal review of the way the Home meets their care needs. During the inspection of the Home, records of Residents care were found in the upstairs lounge unattended. A member of staff was asked about this and it was learned that the records kept in this location were always unattended when staff were busy elsewhere in the Home. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 10 It was found that the records of Service Users health needs were appropriately maintained, although the Home did not keep a record of Residents meals. This record once maintained needs to be kept for three years. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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): These Standards were not examined during this inspection of the Home. EVIDENCE: Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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): Standards 16 & 18. The protection policies and procedures provided by the Home meant that Residents were well protected. EVIDENCE: The complaints procedure provided for Residents was seen and found to provide details on how to refer a complaint to the Commission, if the Resident or their relatives wished to do so. It stated that all complaints would be addressed within 28 days. The Registered Provider had a good policy to protect Residents from abuse and the Acting Manager was aware of the Derbyshire Adult Protection Procedures sponsored by the Local Authority. The Acting Manager agreed that she referred staff to the Protection of Vulnerable Adults register when appointing new staff to the staff team, and that she would also notify the register of any staff she dismissed under worrying circumstances. The Home had polices and procedures for handling Residents money, which included a section preventing staff from benefiting from or assisting in the making of Residents wills. However, the Acting Manager said that the Home did not have copies of the Public Interest Disclosure Act 1998 or the Dept of Health’s guidance called ‘No Secrets. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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): Standard 19. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour of the public areas of the Home was made. The Home was found to be maintained to a very good standard, and was well decorated throughout, although some minor attention was needed, as listed below. The dining room, lounges, conservatory and public areas of the Home were inspected. The following areas needed attention within the Home: The bathroom opposite the lounge, on the ground floor, does not lock appropriately and needs attention. Again on the ground floor, the bathroom by the entrance to the dining room has no lock fitted to it at all. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 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): Standards 27, 29 & 30. The Registered Providers were found to be providing more than adequate staffing in the Home to ensure that Residents needs were met. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the three weeks beginning 7 to the 21 November 2005 the Home was providing between 84 and 127 hours of care a week more than the minimum amount required for 40 Service Users at the High Dependency level. These figures were calculated without the Acting Manager’s working time included, as recommended by the Residential Forum. However, across all three weeks reviewed, 6 staff were found to have worked a number of double shifts in one day of 12.5 hours. One member of staff was found to have worked 5 days, 5 days and 4 days of 12.5 hours per day across the three-week period. This does not encourage staff to meet the needs of Residents in a kindly, understanding and patient manner. The staffing records of two staff employed since April 2002 were examined. These showed that the Acting Manager had obtained almost all of the Requirements necessary, although some was missing. CRB checks and references had been obtained for both members of staff, as had details of their physical and mental fitness for the job. However, a photo had only been Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 15 obtained for one member of staff and detail of relevant qualifications and a full personal history had not been obtained for either member of staff. Staff induction and foundation training was provided for all new staff that came to work in the Home. The Acting Manager also said that all care and nursing staff were provided with at least three paid days training a year. All staff also had an individual training and development assessment and profile. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 16 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): Standards 31, 33 & 38. Satisfactory management systems for the Home were established, thus Service Users benefited from a well run and managed establishment. EVIDENCE: The Acting Manager had only been in post for three months at the time of this inspection. However, to date she had not applied to the Commission to become the Manager of the Home, although this was her declared intension. She also had not obtained an NVQ qualification at level 4 in Management. The Home was regularly ‘inspected’ by senior managers of the organisation owning the Home, to comply with Regulation 26. The Home provides appropriate levels of quality assurance, by ensuring that forward planning and internal audits are undertaken each year, and that Residents surveys are carried out. However, the views of relatives and friends Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 17 of Residents, and the views of GPs and District Nurses etc is not formally sort on how well the Home is providing care for Residents. The Acting Manager said that all staff had attended training in Moving and Handling, Fire Safety, First Aid, and Food Hygiene. However, all nursing staff and some care staff were still awaiting training in Infection Control. All Residents have been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Home has complied with all necessary legislation, such as Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. Risk assessments had been carried out for all safe working practices in the Home, although the Acting Manager had not provided a written statement of the policy, organisation and arrangements for maintaining the safe working practices. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 18 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 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 3 Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement The Registered Providers must complete the statement of purpose by providing details of the physical environment standards met by the Home. This requirement is listed in the National Minimum Standards, 3rd Edition. The Acting Manager must ensure that each Resident, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records. Records of Residents care must be kept securely locked away within the Home. The Registered Providers and Acting Manager must retain a record of all meals provided in the Home for each Resident, for at least 3 years. Appropriate locks must be provided on all toilets and bathroom doors. The Manager must check, and DS0000002132.V269299.R01.S.doc Timescale for action 1 OP1 4 28/02/06 2 OP7 17 Sch 3 28/02/06 3 OP7 17 28/02/06 4 OP8 17 Sch 4, & 17.4 28/02/06 5 OP19 23 28/02/06 Alexandra Nursing Home Version 5.1 Page 20 6 OP29 19 7 OP31 9 8 OP31 8 9 OP33 24 hold documentary evidence, that all staff employed in the Home, since April 2002, have satisfied the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004. The Acting Manager must obtain a qualification at NVQ level 4 in Management before the 31 December 2007. The Acting Manager must apply to the Commission for approval to become the Manager of the Home, completing any necessary paper work and interviews necessary. To complete the requirements of the quality assurance programme, the Registered Providers and Acting Manager should obtain the views of relatives and friends of Residents, together with other stakeholders on how well the Home is achieving goals for the Residents. 28/02/06 31/12/07 28/02/06 30/04/06 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 Refer to Standard OP18 Good Practice Recommendations The Acting Manager should obtain copies of the Public Interest Disclosure Act 1998 and the Dept of Health guidance called ‘No Secrets’. The Acting Manager should review the length of time care staff are allowed to work in the Home, and where possible limit this to no more than one shift per day and 40 hours each week. All nursing staff and relevant care staff should attend training in Infection Control. DS0000002132.V269299.R01.S.doc Version 5.1 Page 21 2 3 OP27 OP38 Alexandra Nursing Home 4 OP38 The Manager should provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. Alexandra Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Nursing Home DS0000002132.V269299.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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