Inspection on 10/06/08 for Alexandra Park Home

This inspection was carried out on 10th June 2008.

CSCI found this care home to be providing an Adequate service.

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 Park Home 21/05/07

Alexandra Park Home 11/04/06

Alexandra Park Home 12/12/05

Alexandra Park Home 16/05/05

Alexandra Park Home 13/09/04

Alexandra Park Home 04/05/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Alexandra Park Home 2 Methuen Park Muswell Hill London N10 2JS Lead Inspector Mr David Hastings Unannounced Inspection 10:00 10th June 2008 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 Park Home DS0000010757.V365529.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 Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Park Home Address 2 Methuen Park Muswell Hill London N10 2JS 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) 020 8883 5212 020 8343 7459 Mr David Weston Mr David Weston Care Home 15 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (15), Old age, of places not falling within any other category (15), Physical disability over 65 years of age (8) Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Limited to 15 people of either gender who fall into the category of old age (OP) and of whom no more than 8 people may be accommodated on the ground floor may also have a physical disability (PD(E)) One specified service user who has dementia may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 30th November 2007 Date of last inspection Brief Description of the Service: Alexandra Park Home is a care home for fifteen older people some of whom may have mental health problems, up to eight people may be accommodated on the ground floor may also have a physical disability and one specified service user who has dementia. There are nine single bedrooms and three shared rooms. No bedrooms have en suite facilities, although there are a number of toilets plus two bathrooms. Alexandra Park Home is not purpose built and comprises of a large converted house with an extension on the ground floor. The home is situated in a quiet residential area of Muswell Hill and is not far from local shops, other amenities and Alexandra Park. Transport links are very good. The home’s stated aim includes that ‘residents’ rights are at the top of our care philosophy. We will advance these rights in all aspects of the home and encourage our residents to take part fully in decision-making’. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The current scales of charges are from £400 to £600 per week. Other additional charges include, hairdressing, chiropody, newspapers and magazines. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This Key Unannounced inspection took place on Tuesday 10th June 2008 and was completed on the same day. The inspection lasted six hours. We spoke with four staff on duty during the inspection. We spoke with five residents of the home and we observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. Residents we spoke with said they were happy with care and support they received. One resident told us, “I’m happy here”. What the service does well: What has improved since the last inspection? What they could do better: Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 6 The registered manager is not always following the home’s recruitment procedures and residents are potentially being put at risk because of this. One immediate requirement was issued at this inspection because the Commission needed the manager to take action to protect residents at the home. Record keeping, in general is not satisfactory and more accurate information is needed in relation to checking the fire alarm and notifying the Commission about incidents at the home that may affect the well being of residents. The current systems in place to manage residents’ money are not robust enough to prevent the risk of financial mismanagement. Staff hand washing arrangements are not in place to limit the risk of cross infection. The fire exit on the first floor to the garden area must be checked so that it is safe for residents to use. Seven new requirements have been issued relating to these matters. A requirement from the last inspection that results of quality monitoring surveys are collated, published and made available to residents and other interested parties has not been complied with and is restated. Four good practice recommendations have been made as a result of this report. Information for residents should be provided in large print formats so that people with sight problems can read them more easily. Better systems should be devised so that residents can have more of a say about their care and how the home is run. Night staff should undertake fire drills at night so they are confident about what action to take in the event of a fire occurring at night. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 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 Park Home DS0000010757.V365529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 not applicable) People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have accurate information about the home in order to make an informed choice about where to live. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. EVIDENCE: We examined the home’s “Statement of purpose” and “Service user guide”. These documents describe the aims and objectives of the home and the facilities available to people coming into the home. These documents also inform social workers looking for placements for people. These documents contained clear information to prospective residents about what services are available as well as the aims and objectives of the home. There was a clear statement that people from different backgrounds and Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 9 cultures are encouraged by the home. The print size of the document was quite small and people with sight problems may find it hard to read. A good practice recommendation has been issued that the service user guide is available in large print format so that it is easier to read. Four assessments were examined of people who had moved into the home. These assessments were detailed and covered all the elements required by this Standard including the assessment of physical, emotional, social and cultural needs. We also found that the information from these assessments was being recorded on peoples’ care plans as well. One resident we spoke with confirmed that they had visited the home before deciding to move in. There was evidence that people moving into the home have a review of their placement after four to six weeks to see if they are happy at the home and whether they decide to move in on a permanent basis. All the residents we spoke with said they were happy with the care they received. Alexandra Park Home DS0000010757.V365529.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Five care plans were examined. Each plan had a detailed description of the person’s care needs including their physical, emotional and social needs. Each plan gave clear instructions to staff about how best to care for each person. Risk assessments were being carried out in relation to fire safety, pressure care and other risks associated with the individual’s mental health. These plans were very person centred and concentrated on the person’s remaining strengths and abilities as well as their care needs. Work has been undertaken to gain a social history of people at the home so that staff can have an insight into what the person was like before they moved into the home. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 11 Visits by health care professionals such as doctors, district nurses, chiropodists, dentists and opticians were being recorded on plans we examined. These showed that people had good access to these professionals. This was also confirmed by residents we spoke with. Care plans were being reviewed but there was little evidence that residents had been involved in the review of their plans. Although all the people we spoke with said they were happy with their care, it is important that people are given an opportunity to decide if they want changes to their plan of care. A good practice recommendation has been issued that people are consulted about their care and the quality of the care they receive on a regular basis when their care plan is being reviewed. On the day of the inspection residents appeared relaxed, appropriately dressed and well cared for. Records and procedures were examined in relation to the receipt, storage, administration and disposal of medication. These records were generally satisfactory, however we saw that some medication coming into the home was not always being recorded. The manager told us that this was an oversight and we did see records from the previous month that showed all medication was being recorded properly. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. One person told us, “They respect my privacy”. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. Visitors to the home are encouraged and welcomed. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: Although the morning was very busy in the afternoon staff were observed sitting and chatting with residents and residents were clearly benefiting from the staff contact. The hairdresser was visiting in the morning and a number of residents were having their hair done. The manager told us that the activities coordinator had left the home and that he would be employing a new activities worker shortly. There is a visiting occupational therapist who comes to the home every week. We saw examples of residents taking part in occupational activities such as folding napkins. A requirement was issued at the last inspection that people who use the service are enabled to go out of the home and take part in appropriate leisure pursuits. The manager and staff told us that they take residents out to the local shops or for a walk. More mobile residents are able to Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 13 go out of the home and have appropriate risk assessments in place. People told us that they did go out of the home and records we examined confirmed this. The manager said that he organises trips out to Alexandra Palace, which is near by. Residents told us that they could have visitors at any reasonable time and the manager confirmed that the home has an open visiting policy. He also said that most residents at the home have visitors. We saw the visitors’ book, which confirmed that people could visit at any reasonable time. Residents said that visitors were encouraged. The home does not have residents’ meetings but residents told us they could have a say in how the home is run and could choose what to do with their day. One person told us, “It’s fairly free and easy, you don’t get bossed about”. As the home does not have regular residents meetings a good practice recommendation has been issued that the management of the home find other methods to find out how satisfied the residents are with their care. This could mean that yearly quality assurance questionnaires take place more regularly and or residents are asked about their care when staff are reviewing individual care plans each month. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. We saw examples of staff offering choice in relation to meals and activities during the inspection. The kitchen was inspected. Fridge and freezer temperatures were being recorded and there were sufficient amounts of fresh fruit and vegetables available. The cook was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. The meals we saw on the day of the inspection looked and smelt appetising. People who use the service confirmed that the food was good at the home and that they always get enough to eat. On person commented that the vegetables could sometimes be over cooked but acknowledged that this may be because of older, frailer people living at the home. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People who use the service are not being fully protected from abuse because recruitment procedures are not always being followed. EVIDENCE: The manager told us that there had not been any complaints about the service since the last inspection. The home has a satisfactory complaints procedure and people we spoke with said they had no complaints but would speak to the manager if they did. Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. The home has a satisfactory policy and procedure in relation to safeguarding vulnerable people. Records indicated that staff have undertaken training in the protection of vulnerable people. The manager told us that an adult protection matter had arisen at the home and had been investigated by the local authority and had been unfounded. However the registered person did not notify the Commission about the matter. This is a requirement under Regulation 37 of The Care Homes Regulations 2001. The manager told us that the local authority had told him Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 15 they would contact the Commission. It is the responsibility of the registered person to inform the Commission of any allegation of misconduct by staff at the home. A requirement has been issued relating to this matter in the relevant section of this report. As detailed in the staffing section of this report recruitment practices are not always being followed in order to protect people who use the service. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and furnished and decorated to a good standard. EVIDENCE: The registered manager showed us around the home and we met with some residents in their rooms. The home is decorated and maintained to a good standard. The home was clean and fresh. People we spoke to said the home was always clean. One resident told us, “They come in and clean every day”. The home employs domestic staff. The water temperatures of wash hand basins in peoples’ rooms were checked and found to be within safe limits so residents cannot accidentally scold themselves. Bathrooms and toilets were clean but did not contain anti bacterial soap or paper towels to limit the risk of cross infection. The manager did tell us that the home had a stock of these materials and was unclear as to why they were not being used. A requirement has been issued in the relevant section of this report. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 17 Clothes were being sorted in the laundry area and the washing machine has a sluice cycle to wash soiled linen properly. Records indicated that staff have attended infection control training. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home work very hard to meet the needs of the residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are not sufficiently detailed in order to protect residents at the home. EVIDENCE: We examined the staffing rota, which indicated that two care staff are on duty throughout the day and two waking night staff are on duty throughout the night. Residents we spoke with were positive about the staff. One person told us, “The staff respect me and my wishes”. Staff turnover at the home is low and staff said that staff morale is high. Staff were very positive about the training offered to them by the home. Most staff have completed their NVQ level 2 or equivalent and appropriate training certificates were seen on staff files we examined. Four staffing files were examined. Three files were satisfactory however a requirement has been issued that all written references are authenticated by the manager either by requesting a company stamp or letter headed paper or by phoning the referee to check the reference. This is because some references were handwritten and did not contain evidence that they were from the last employer. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 19 One staff file examined did not contain a CRB disclosure or two written references. This is unacceptable and puts residents at risk from unsuitable staff being employed at the home. The homes’ own recruitment procedure was not being followed. The manager took the staff member concerned off the rota immediately and told us he would provide suitable cover until the required documents had been received. An immediate requirement was issued relating to this and the manager was informed that he must ensure that all staff files contain the information required by Regulation 19 of the Care Homes Regulations 2001. The manager told us later that the staff member in question had been working as an agency staff at the home before being employed full time and so it was presumed that the agency had carried out the required checks. It is important that the manager checks with every agency staff that they have the required recruitment checks before they work at the home. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents have few opportunities to have a say in how the home is run. Residents’ financial interests are not being properly safeguarded. The health and safety of residents and staff are generally being promoted and protected. EVIDENCE: Both residents and staff were very positive about the registered manager, Mr David Weston. One resident commented that the manager was, “Very nice, very helpful”. Staff told us that the manager was very approachable and that he had a good rapport with staff and residents. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 21 It was clear from discussion and from observation that the manager understands the needs of people with mental health problems. The manager is a qualified Mental Health Nurse. We are concerned that the manager is not always following the home’s procedures in relation to staff recruitment and notifying the Commission about any incidents that affect the well being of residents as detailed elsewhere in this report. These procedures are put in place to protect people who use the service and failure to comply with the Care Homes Regulations 2001 not only puts residents at risk but also could lead to further action being taken by the Commission. A requirement was issued at the last inspection that a system be established to monitor and improve the quality of care provided by the home. Surveys have been sent to residents and their representatives but the information from these has not been collated or published. As there are no resident or relatives meetings at the home it is very important to obtain feedback about how well the home is doing to meet the aims and objectives of the service. Regular surveys give residents the opportunity to comment on the running of their home. The requirement has been restated. Residents’ finances were inspected. A number of people are assisted to manage their money by the registered manager and money is held by the home on their behalf. Satisfactory receipts were being maintained for individuals in relation to hairdressing, chiropody and other minor purchases. A record was being kept of resident’s money being received by the home, payments made and an updated balance of how much money individual residents had left. Resident’s money was being held by the manager and as such it was impossible to audit individual accounts as all the money has been pooled. This means that residents or their representatives cannot be sure that their account is accurate. A requirement has been issued that the system for managing people’s money is reviewed so that individual accounts can be accurately audited. This could mean that individual saving accounts are set up for residents so they have access to their money. A requirement was issued at the last inspection that all staff must receive regular supervision. We saw evidence of regular supervision on some staff files we examined. The manager has set up new systems for supervision and appraisal for all staff. A requirement was issued at the last inspection that the manager must update the environmental risk assessment for the home and ensure that all residents have assess to the garden area. A satisfactory, updated environmental risk assessment was seen and the manager has now fitted a ramp to the garden area so that people who use wheelchairs can assess the garden. The local fire officer inspected the home in January of this year. As a result of this inspection four items were identified as requiring action by the registered Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 22 manager. The manager has addressed three of these issues. The remaining issue is regarding the fire escape from the first floor to the garden area. This fire escape requires a safety compliance certificate to confirm that it is structurally safe. A requirement has been issued that the registered person must comply with the items identified in the fire officer’s report. Fire records were examined. The fire alarm weekly checks were not always being recorded and as such there is no written evidence that these took place. This is important as the fire alarm is regularly checked so that any problems can be identified and resolved. A requirement has made relating to this issue. Records indicated that staff were undertaking fire drills on a regular basis. It would be prudent to ensure that night staff undertake regular fire drills every three months so they are confident about what action to take if a fire occurs at night. A good practice recommendation has been made. Other satisfactory records were seen in relation to electrical, gas and water safety. The home has been inspected by the local environment health department and has been awarded three stars for “The scores on the doors”, which means that the home has satisfactory food safety standards. Alexandra Park Home DS0000010757.V365529.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 3 X 3 X X N/A 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 X 2 Alexandra Park Home DS0000010757.V365529.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 OP33 Regulation 24(1)(2)( 3) Requirement The registered person must establish and maintain a system for- (a) reviewing at appropriate intervals; and (b) improving, the quality of care provided at the home by consulting people who live at the home, their relatives and professionals. The registered person must supply the Commission a report in respect of the quality review and make a copy available to service users. The quality assurance system will enable people who use the service to make comments and help the home to improve the services. Timescale for action 01/08/08 2. OP18 37 Timescale of 31/03/08 not met. This requirement is restated. The registered person must 01/07/08 ensure that the Commission is notified of any event, which affects the well being of residents at the home. This should ensure that the Commission is aware of any such events and can take appropriate action if required. DS0000010757.V365529.R01.S.doc Version 5.2 Page 25 Alexandra Park Home 3. OP26 13(3) 4. OP29 19 5. OP29 19 6. OP35 13(6) 7 OP38 23(4) 8. OP38 23(4) The registered person must ensure that staff have assess to anti bacterial soap and paper towels to reduce the risk of cross infection. The registered person must ensure that no staff are employed at the home without first receiving the recruitment information including two written references, proof of identity and a satisfactory CRB disclosure. This is to ensure the safety of residents at the home. This was an immediate requirement issued on the day of the inspection. The registered person must ensure that all written references are authenticated by the manager either by requesting a company stamp or letter headed paper or by phoning the referee to check the reference. This is to ensure the safety of residents at the home. The registered person must ensure that the systems for managing residents’ finances at the home are reviewed so that an accurate audit of individual’s accounts can be made. This is to ensure that residents’ finances are not open to potential mismanagement. The registered person must ensure that the metal fire escape is inspected by an appropriate person and a safety compliance certificate is available fro inspection. The registered person must ensure that records are maintained of the fire alarm being tested every week. 01/08/08 13/06/08 01/08/08 01/08/08 01/08/08 01/08/08 Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 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. 3. 4. Refer to Standard OP1 OP7 OP14 OP38 Good Practice Recommendations The registered person should ensure that the Service user Guide and Statement of Purpose are available in large print formats. The registered person should ensure that residents are consulted about their care and the quality of this care when staff are reviewing care plans with them. The registered person should ensure that systems are devised so that residents can be consulted and have a say in how the home is run. The registered person should ensure that night time fire drills take place so that staff working at night are confident about what to do in the event of a fire. Alexandra Park Home DS0000010757.V365529.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexandra Park Home DS0000010757.V365529.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. 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