Inspection on 10/07/07 for Alexandra Way EPH

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexandra Way EPH 14/06/06

Alexandra Way EPH 08/03/06

Alexandra Way EPH 29/06/05

Alexandra Way EPH 09/03/05

Alexandra Way EPH 29/11/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Alexandra Way EPH 3 Alexandra Way Thornbury South Glos BS35 1LA Lead Inspector Jon Clarke Key Unannounced Inspection 10th July 2007 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 Way EPH DS0000035376.V344283.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 Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Way EPH Address 3 Alexandra Way Thornbury South Glos BS35 1LA 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) 01454 866172 01454 866828 lynne.smith@southglos.gov.uk South Gloucestershire Council To be appointed Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person under the age of 65 years. Registration will revert when the named person reaches the age of 65 or leaves. 14th June 2006 Date of last inspection Brief Description of the Service: Alexandra Way is a Local Authority Home for older people. It is situated some distance away from the centre of Thornbury, an ancient market town. The home, whilst a good fifteen-minute walk from town, is well situated to access Bristol, Gloucester and the M4 and M5 motorways. The town offers all of the usual shopping, banking, and sporting and spiritual amenities. It boasts its own festival and many amateur music and drama groups. The home is situated in well kept, extensive grounds and also has the advantage of being in a Cul-de-Sac. The building is on one level and divided into wings leading to a central courtyard garden area. There is a large dining room and separate lounges. As the service user population has aged, some of the facilities have become obsolete and some have had a change of designation. Service Users or families no longer use the small kitchens that lead from each of the three lounges. Three of the former bedrooms are now: a reminiscence room; a key worker room; a craft room. Two rooms are dedicated respite care rooms and the remaining thirty-five rooms accommodate the Service Users. The home also offers three places for service users who benefit from day care placements. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home as part of an inspection. As part of the inspection a number of documents were looked at included were care plans, medication records and arrangements for their storage and administering, staff selection, training and health and safety. There was also an opportunity to discuss with individuals who live and work in the home their experience and views about the quality of the service they receive and provide. What the service does well: After a period of change following a number of home managers and staff changes there is now a sense of stability with a management team that has clearly worked hard to improve morale and establish greater continuity and consistency of care. This was commented on by individuals I spoke to “things are a lot better then they used to be”, “I feel it’s more settled now”, “staff are better”. Staff also spoke positively about the management team: “before we didn’t know who was going to be here now things are better” “they are all approachable” “tell them something and it will be sorted”. Staff clearly make an effort to meet the care needs of individuals who live in the home and this was confirmed by some I spoke with “they understand what help I need” “you only have to ask and they will help”. An area of potential real improvement is the environment of the home with main communal areas of the home lounges, dining area, corridors all planned for re-decoration and updating. Of note is the effort to provide not only a homely environment but importantly to assist those individuals who may have difficulties around disorientation or confusion to use various colour schemes to identify particular areas of the home. Comments about the home and quality of care included: “I do feel the carers are very good. They are kind, patient and caring.” (resident) “Residents are treated with care and respect. Their own private needs are well noted and communicated to other shifts” (relative)” Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alexandra Way EPH DS0000035376.V344283.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 Way EPH DS0000035376.V344283.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): 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose provides the required information about the home, the facilities, staffing arrangements, admission procedure and aims and objectives of the home so that individuals can make an informed choice about the suitability of the home. The home undertakes full and comprehensive assessment of prospective residents so that they are able to make an informed decision about the capacity of the home to meet health and social care needs. EVIDENCE: The home’s Statement of Purpose gave full information about the care provided in the home and details about the “routines” of the home such as meals, activities and staffing. It also gave details of how to make a complaint including the right of individuals to contact CSCI if they wished. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 9 I examined a number of pre-admission assessments which had been undertaken by the local authority. They provided information about the health and social care needs of the individual including medical conditions and any mental health difficulties. The home’s Statement of Terms and Condition was looked at and failed to give information about any increase in fees and period of notice of such increases and why they are being made. As in other South Gloucestershire contracts it also refers to individuals as “permanent guest” inferring in my view that living in the home is of a temporary nature e.g. guest and importantly it is not somewhere which should be consider and seen as the individual’s home? Alexandra Way EPH DS0000035376.V344283.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Planning and arrangements for meeting health care are generally good providing staff with the necessary information so that the health and social care needs of residents are met. Arrangements for managing resident’s medication make sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld. EVIDENCE: A number of care plans were looked at and showed that generally there is good information about the specific needs and care tasks of the individual. They had been reviewed regularly and moving and handling assessments reviewed in one instance on a monthly basis. One individual who had experienced a number of falls had been referred to a physiotherapist. One also had very detailed information about the moving and handling tasks. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 11 Daily Living plans had been completed as well as risk assessments (in one instance where individual was diabetic), care plans were signed by the individual. Part of the Care Plan was the completion of weight chart these were not completed consistently: one individual only entry was May 06, another April 07 and May 07 others had limited or no entries over long periods. One individual who was receiving support from district nurse because of pressure sore had no specific information about her care needs relating to prevention of skin breakdown or risk assessment providing guidance around skin care for that individual. Individuals who live in the home have access to the range of community health services with chiropody, dental and optician being provided where necessary. The home has good links with community nurse service who visit the home where individuals need “nursing” care. Community nurse in one instance had completed a falls screening where an individual had history of falls. Medication administering records were looked at and showed accurate recording of medication given to individuals, a control drugs register was completed with two signatures as required. Returns of medication are signed as being received by the pharmacist or their representative. There are safe arrangements in place for the storage of medication. It is the practice of the home that where individuals are able they can selfadminister and manage their medication. A risk assessment had been completed where one individual had chosen to self-medicate. In talking with individuals they spoke positively about how staff treated them with respect: “you can’t fault them” “they always treat me as I would want very caring”. In observing staff they approached individuals with sensitivity and addressed individuals with respect and in a way which was supportive and caring. Individuals confirmed that they felt their privacy was respected and staff were observed knocking on rooms and waiting for a response. One person I spoke too said she never felt “staff intruded” on what she did and how she spent her time another said she chose to spend a lot of her time in her room and this was never questioned by staff. Alexandra Way EPH DS0000035376.V344283.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: The home employs an activities organiser though at present she is on sick leave. One individual I spoke to said that there was, as a result, a lack of activities in the home. However, in looking at the activities record there was evidence of regular activities taking place. These range from bingo, exercise, film shows and outside entertainers. On the day of my visit there was an outside entertainer. Another individual I spoke to said they felt there was enough activities for them. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 13 Staff told me that they always try and organise activities and when asked whether they felt there was enough time for them to do this they said that there was. Individuals I spoke to said how the home “always” welcomes visitors and spoke of how welcoming staff were towards their friends and relatives. I asked individuals about the routines in the home and their ability to choose how they spend their day. All of those I spoke with said they felt there were no “real restrictions on us” “I can do as I like really” “its up to me” “do whatever I want” were typical comments. When asked about routines such as bathing, getting up and going to bed comments included “give me the choice” “very free” “get me up when I want”. I asked one individual about bathing and what was the response of staff if she said she didn’t want to have a bath at the time offered she said “I can say if its not a suitable time”. The home has recently introduced a new 4-week menu. There were mixed comments from individual about the food and meals provided: “quality not as good as should be” (this individual said there had been improvement over the past two weeks) “very good always a choice if I want something different” “I enjoy the meals here breakfast is very good”. The menu had been discussed at the residents meeting and looking at the menu there was a good range of meals being offered. Meals are provided which suit any medical conditions or specific health needs relating to diet. I joined residents for a meal which was well presented. There was an unhurried atmosphere and staff were observed offering support and assistance in a sensitive and dignified way to those that needed help. Alexandra Way EPH DS0000035376.V344283.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area. EVIDENCE: Since the previous inspection there have been two complaints one concerning state of individuals room this was satisfactory resolved with re-decoration and replacing of flooring the other was concern about the management changes which has now also been addressed by the permanent appointment of the manager. I spoke to a number of individuals about their knowledge of how to make a complaint and what they would do if unhappy about anything. All were aware of the home’s complaint procedure which is displayed in the home and also forms part of the Welcome Pack. They all said how they would speak to a manager and importantly “they would do something about it” “they listen to what we have to say” being typical responses. They also described staff and manager as “approach them at any time” “always there if we want them”. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 15 There is an Adult Protection policy and procedure in place and staff undertake training in Safeguarding Adults. When speaking to staff they were very clear about their duty to protect individuals who live in the home. Alexandra Way EPH DS0000035376.V344283.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and hygienic environment for the residents and staff. EVIDENCE: As noted in this report there is extensive re-decoration of the communal areas of the home and this is currently taking place. Areas which have been completed, namely the corridor, were a lot brighter and welcoming. The plans to decorate communal areas will no doubt improve the environment and enhance the lives of those that live in the home. Individuals I spoke to too were very positive about the planned improvements and had been part of the decision about the choice of colours and wallpapers being used in the redecoration. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 17 At the time of this visit the home was clean and free from any offensive odours. Staff have training in infection control and are familiar with ways of protecting individuals through the use of protective clothing and procedures are in place to maintain hygiene. Alexandra Way EPH DS0000035376.V344283.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected. EVIDENCE: I looked at the staffing rota for period of a month and these showed that there was adequate staff on duty at all times. Generally there are 5 staff on duty am, 4 2-10 and 2 waking night with 3 domestic staff. In addition there is a member of the management team on duty. There is improved retention of staff since the appointment of new management team and whilst there has been use of agency staff this is infrequent and result of sickness or annual leave rather then covering of vacant posts. Wherever possible agency staff who have previous worked in the home are used to provide cover and on day of my visit an agency staff member confirmed that she had worked in the home before. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 19 Currently there are 26 care staff of which 10 have NVQ qualification with further 9 working towards this qualification. Three staff are also undertaking training to form part of the new type of worker which entails learning about nursing type tasks as part of this scheme being introduced to the home. Recruitment and selection records showed that the required checks and procedures are in place when recruiting staff. Full and detailed application forms had been completed which included full employment history, two references had been obtained and Criminal Record Bureau check had been undertaken. Training records evidenced that staff had completed “mandatory” areas of training such as moving and handling, medication, fire safety, first aid, Adult Protection. In addition staff had been offered and some had completed training in Depression and Older Adults, Communication and Dementia and Anger and Dementia. Alexandra Way EPH DS0000035376.V344283.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): 31,33,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good opportunities for residents and others to express their views about the service they receive. The practices of the home help to make sure that the health, safety and welfare of residents and staff is protected. EVIDENCE: The manager of the home has extensive experience of working in a care home setting; she has yet to be registered with the CSCI. Staff and residents all spoke of her as someone approachable. One member of staff said that they could always go “and speak to her about anything and she will listen to you” this was agreed with by other members of staff. They all felt morale had improved since her appointment. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 21 A resident spoke of her as again someone they would always feel able to go to if they had a problem or concern “she always there if we want her” was a common response. There is a quality assurance system in place where questionnaires are sent to individuals who live in the home and relatives. I was unable to look at any results in that the latest survey results were still being drawn up and conclusion being made. However the manager told me that there had been 95 satisfaction with the care provided in the home. Resident’s meeting are regularly held which provide an opportunity to involve individual in the life of the home and importantly express their views about the quality of the service they receive. Minutes that I looked at showed that the home’s menu had been discussed and suggestions made as to changes and activities had also been raised. Health & safety records I looked at showed that all staff including night staff had undertaken the required fire drills. Regular checks of fire equipment, emergency lighting are undertaken. Environmental fire risk assessment had been completed and risk assessments around the decoration including having other employees in the home (i.e. decorators). Staff records showed that staff receive regular supervision and staff that I spoke to also confirmed this. Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 22 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 2 3 X X X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alexandra Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Way EPH DS0000035376.V344283.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!