Inspection on 14/06/06 for Alexandra Way EPH

This inspection was carried out on 14th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 10/07/07

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 Grace Agu Key Unannounced Inspection 14th June 2006 09:15 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.V299971.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.V299971.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 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.V299971.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. 8th March 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, 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 also having the advantage of being in a Cul-deSac. 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 and 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.V299971.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 inspection, which took place over eight hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. In addition to the above, the inspection was undertaken in response to the regulation 37 notifications received at the Commission for Social Care Inspection in relation to alleged injury to the right arm of a resident by another resident and unexplained bruises noted on an individual by a relative after a period of respite at the home. This incident was reported to the Adult Protection Team and two strategy meetings were held in order to establish the cause. The other incident was in relation to a medication error. As a part of this inspection four immediate requirements were made in relation to medication malpractices and making arrangements for staff members to attend fire drills. A tour of the building was undertaken and a number of records were reviewed. Twelve residents and four staff members were spoken with during the inspection. What the service does well: General discussion with residents, staff members and the manager evidenced positive attitude towards the home. The manager stated that the resident are more relaxed and are encouraged to be involved in activities in order to improve their emotional well-being. The manager also stated that the home provides a safe environment for the residents and that residents are encouraged to air their views in all areas of service provided. The home provides meaningful activities to its residents and ensures that individual interaction is provided if necessary. In order to ensure adequate nutrition for the residents, good meals are provided and are not hurried; those who are unable to feed themselves are fed in a respectful, sensitive and dignified manner. Residents are protected are enabled to complain through a robust complaint procedure that ensures all complaints are thoroughly investigated and complainant informed of the outcome. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 6 In addition, to ensure that residents are adequately protected, ongoing training courses are provided for staff and a stringent recruitment procedure is followed for all persons that are employed at the home. The home is adequately staffed to include care and domestic staff. The home ensures that aids and equipment are provided in sufficient quantity to assist staff with meeting the needs of the residents. What has improved since the last inspection? What they could do better: At the last inspection, three requirements were made. It was noted that one requirement has not been met. This requirement included replacing the identified carpet in one of the lounges. The manager stated that this carpet will be replaced during a planned refurbishment taking place at the home soon. The manager must ensure that this requirement is met in line with the legislation. The requirement remains in place. The manager is also reminded that failure to meet this requirement could lead to enforcement action At this inspection it was agreed that all staff records must be present at the home for inspection to comply with the legislation. All medication administered must be signed for, all medication not administered must be properly recorded to prevent drug errors and to protect the residents. Furthermore all hand written medication must be signed and dated. All Controlled drugs must be clearly written in the Medication Administration Record Sheet and all unwanted medication must be returned to the pharmacy for safe disposal. To ensure that staff are aware of measures and procedures to follow in fire emergency, regular fire drills must be provided for all staff. Residents would be better protected if comprehensive and detailed care plans are in place for all residents to ensure that their needs are adequately met. To ensure that the nutritional needs of the residents are met at the Home it would better if residents were consulted when the menu is changed. Furthermore the residents would enjoy a comfortable environment if the heavily stained carpets identified in two lounges are replaced. Whilst reviewing the medication, it was noted that the Controlled drugs were being recorded in loose leafs of paper. It was recommended that this practice Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 7 be reviewed to record the Controlled drugs in a bound book to ensure that vital information is not missed out. 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 Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission to ensure that their needs will be met. EVIDENCE: The care records of two recently admitted residents were viewed. There were detailed assessments from the Care Management Team to include physical, mental and social needs. This assessment was undertaken to ensure that the needs of the resident would be met at the home. One of the residents whose care file was viewed confirmed that they were visited and assessed at home before admission. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission, however the care planning and medication administration procedures fail to offer protection to the residents EVIDENCE: Five care files were reviewed at this visit. All the care files contained pre admission assessment to determine how the home was to meet the needs of the residents. The care files viewed included two of the most recently admitted residents. Whilst the care files contained evidence of risk assessments, weight monitoring and daily reports on how the care was provided the “Provider Service Plan” noted in the files were not explanatory of how staff were to meet the identified needs holistically. Staff spoken with stated that there is a sense of instability at the home due to changes in management over a period of two years. Staff would normally be Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 11 informed if a new resident is coming in through handovers and by talking to the residents about their care needs if they are able. The acting manager met on the day stated they are aware of the short falls in the care plans and that efforts are being made to develop care plans that reflect the needs of the residents. A sample of the proposed care plan to be introduced was noted at the home and this will be reviewed at the next inspection. A requirement was made for care plans to be developed for residents recently admitted to ensure that their needs are adequately met Residents spoken with stated that staff treated them well, “staff look after us, staff answer when we ring the bell”. One resident confirmed that staff respect them and ensure privacy whilst assisting them with personal care. Care staff were noted knocking at the doors and waiting to be allowed in before going into bedroom to assist residents. There was evidence of doctor and other health professional visits to include, chiropodists, district nurses and physiotherapists for routine or urgent appointments. This inspection followed up the Regulation 37 sent to the commission in relation to a medication error at the home. The acting manager stated that the matter had been satisfactorily resolved. In relation to the resident who was found with injury on the arm caused by another resident, records and discussion with the manager evidenced that the alleged resident had been referred to the mental health team for a review and possible transfer to a more appropriate care setting. At this inspection, it was disappointing to note that medication administration practices were unsatisfactory. It was noted that some medication hand written on the Medication Administration Record Sheets (MARS) were not signed and dated and some medication administered were not signed in the MARS. Furthermore, whilst it was noted that the Controlled drug had a correct balance and was administered by two staff members, it was recorded in loose leafs of papers (a bound Control Drug book was noted in the cupboard but it was not being used) and it was not written correctly on the MARS. The Acting Manager stated that recording Controlled drug in loose leafs was the council policy however the home would record the Controlled drugs in the bound book to prevent the risk of loosing information if the loose leafs were lost or destroyed. It was noted that the resident was admitted to the home with different doses of the controlled drug to enable the medical team to provide adequate pain control to the individual. The resident was reviewed and one single manageable dose was prescribed. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 12 However the unwanted doses were still stored at the home. This practice poses a potential risk of medication error. This also confirms the findings of poor practice in relation to medication administration noted on the providers visit (Reg. 26) report on 06/06/06. An immediate requirement was made to correct the above-identified discrepancies. A requirement in relation to disposal of unwanted doses of the controlled drug and ensuring that the controlled drug was correctly written on the MARS was met before the end of the inspection. An action plan stating how the council was to meet the rest of the immediate requirements made was received at the Commission within the timescale set. Staff demonstrated knowledge of keeping information about residents confidential. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home enables the residents to maintain contact with families, friends and representatives; it provides meaningful activities and satisfactory meals at chosen times. EVIDENCE: On the day of inspection, groups of residents were noted relaxing in different lounges and some were in their rooms, Residents spoken with stated that they would attend activities. One resident stated, “I am happy to stay in my room”. The home employs an activities person who is responsible for suitable activities for the residents based on individual capabilities. One staff member spoken with stated that some residents participate in activities whilst others find activities less stimulating. In relation to the latter having a one to one conversation is more appealing. Details of all activities offered to the residents and list of participants are recorded in the activities book and care files. Recorded activities seen included Coffee morning 25/05/06 (twenty four residents), Bingo 21/05/06 (Eleven residents), Mobility exercises 25/05/06 (thirteen residents) trip to the Garden Centre 18/05/06 (Seven residents) Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 14 Dominos 29/05/06 (Four residents). Evidence of Key worker recorded interactions with residents were noted in the key worker files. Also noted were the photographs taken whilst residents were taken on trips. Residents spoken with confirmed that the home actively supports them to maintain contact with their families, friends and representatives. One resident stated, “ My niece comes to see me regularly”. Another resident stated that the daughter visits often. In relation to daily routine, residents spoken with stated that they have a choice of when to get up and retire. One resident stated, “ I get up when they bring me a cup of tea”. The menu contained two meals and looked delicious however it was noted that the menu on the day was different from the meal served to the residents. One resident stated on a comment card that “ the food is good but very plain and needs more variety” another resident stated “ Menu could be better very tasteless and not much change, had sandwiches one day not to my liking would be nice if had a choice”. Some residents spoken with stated that they enjoyed their meal some were not aware of what was on the menu. At a discussion with the manager, it was agreed that the menu needs to be revised to reflect the meal for the day. It was also agreed that the cooks attend residents meeting in order to give the residents the opportunity to participate in preparing the menu. It was noted that a different meal was provided to a resident with swallowing problem, this indicates that the home ensures that residents are nutritionally assessed to ensure that their needs are met. Staff were noted with aprons whilst serving residents and those unable to feed them were seen being assisted in a sensitive and dignified manner. The kitchen was found clean and tidy, there was a risk assessment in place, Staff working in the kitchen have attended Basic Food hygiene training update. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the home offer protection to the residents. EVIDENCE: The home has appropriate procedures in place for management of complaints. The complaints procedure was noted displayed in the hallway at the entrance of the home, this document contains information about the Commission for Social Care Inspection as well as South Gloucestershire Council to enable the resident and or their relatives to contact the Commission if they were not satisfied with the outcome of their complaint to the home. The manager stated that the complaints procedure is issued to the residents on admission. One staff member spoken with stated that residents are supported to complain based on their level of understanding, staff skills and knowledge of the residents. The staff stated “Some of them go quiet. Some will go tearful”. Developing a good relationship with the residents will enable the individuals to trust staff and subsequently have the courage to discuss any areas of concern if they were able to do so. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 16 There were six-recorded complaints since the last inspection. Three complaint recorded were successfully investigated. The manager had planned to meet with two families on 15/06/06 and 08/07/06 in relation to lack of communication and unsatisfactory care of an individual respectively. Two residents spoken with stated that they would speak to staff if they had any complaint however, have no reason to complain. One relative comment card states “ we have no reason to have any concerns regarding the care given to…We are certain that we would be aware of any major (minor) problems” The Commission for Social Care Inspection was informed of alleged unexplained bruises noted on an individual after one week respite at the home, This allegation resulted in two strategy meetings organised by South Gloucestershire Council aimed at establishing how the bruises were sustained. At a second meeting the outcome was inconclusive due to lack of the information required. Furthermore the resident had gone home and was not in danger. The manager of South Gloucestershire homes who was present at the meeting stated that the two staff members who were on duty whilst the resident was on respite had been transferred to another South Gloucestershire home. No further meeting will take place, however the manager would inform the Team of any new development. Staff interviewed were aware of the whistle blowing policy to enable them to report any suspected abuse without reprisal. The manager demonstrated knowledge of the procedure for reporting abuse and also stated all the duty managers working at the home were familiar with the procedure. Records of two recently employed individuals were reviewed. One staff members file contained statutory information to include, two satisfactory references, and record of previous employment, personal details and satisfactory Criminal Record Bureau Disclosure. The record of the second individual was not available at the home for inspection, however one reference was faxed to the home from the personnel department of the Council on request and another reference was sent to the Commission For Social Care Inspection a few days later for inspection. The home must ensure that staff records are available at the home for inspection in line with the legislation. This was followed up with a requirement. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy a safe and odour free environment however some areas of the home have not been well maintained. EVIDENCE: Whilst touring the building the home was found to be generally clean, warm, well lit and free from offensive odour and suitable for its stated purpose Residents sitting in the lounges, looked relaxed, well cared for and enjoying each other’s company. Some residents spoken with stated that they felt safe at the home. At the last inspection a requirement was made for a heavily stained carpet in one of the lounges to be replaced. This requirement had not been met. It was also noted at this inspection that another carpet in a different lounge was heavily stained. The manager stated that the carpet was not changed due to the planned Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 18 refurbishment and this would be included in the plan. The requirement remains. The laundry was found clean and tidy, there were adequate laundry facilities and the laundry staff met on duty stated that residents clothes are placed in individual boxes and are put away by the carers. Residents who are capable are supported to put their clothes away in order to maximise their independence. Soiled clothing is washed separately and staff inform the laundry of any infection at the home. Staff were noted wearing aprons and gloves and washing their hands after attending to the residents. This demonstrated that infection Control and principles of hygiene is well maintained at the home. The maintenance book was up to date clearly stating jobs/ tasks to be carried out, date completed and any relevant comment in relation outstanding jobs Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing level at the home is sufficient to meet the needs of the residents. Staff receive appropriate training and are competent to protect the residents. EVIDENCE: Evidence from staff rota and discussion with the manager showed that the home has a sufficient staffing level to meet the needs of the residents. Residents spoken with stated that staff attended them when they rang the bell. The home operates a key working system to enhance the resident/staff relationship. Staff have attended training to include Dementia Awareness and training in challenging behaviour It was agreed that that more numbers of staff attend updates on the above courses in order to apply current practice in the care of the residents. Other training attended includes Protection of Vulnerable Adults from Abuse, Basic Food Hygiene, First Aid and Control of Substances Hazardous to Health. It was also noted that some staff members have achieved National Vocational Qualification (NVQ) at level 2 and 3. One staff member stated that they were undertaking NVQ at level 2 and hopes to finish in September after completing the remaining four units. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 20 However, it was noted that one staff member employed six months age had not attended Protection of vulnerable Adults from Abuse training. A requirement had been made for this individual to be trained in order to protect the residents. Recruitment had been previously discussed under Protection. It was pleasing to note that the requirement made at the last inspection in relation to fire training for the night staff has been met Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed efficiently however attention needs to be given to formalising the position of the acting manager and ensuring that staff attend fire drills. EVIDENCE: Ms Lynne Smith is the current acting manager at Alexandra Way. Ms Smith is a registered manager of Newton House a sister home owned by South Gloucestershire Council and was brought in to manage Alexandra Way following the departure of the previous manager. The Commission has received no application for registration for registration of a replacement manager. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 22 Ms Smith had undertaken NVQ at level 4 and has almost completed the Registered manager’s award. The manager stated that there is a new management team at the home aimed at reviewing current practices and making changes that would impact on the care of the residents and services provided for them The manager is well supported by the line manager, staff team and the new management team to ensure that the residents receive optimum service. Staff spoken with stated that there is a sense of instability at the home due to changes in management over a period of two years however the Acting Manager is approachable and would listen. At a discussion with a group staff all unanimously agreed that the management had made significant changes in regard to care of the residents and communication with staff since they assumed office two months ago. Residents interviewed were complementary about the manager’s ability to manage the home. The Council needs to give urgent priority to having a permanent manager at Alexandra Way to ensure continuity of care to the residents and to agree to provide a sense of direction to the staff. The home’s Quality Assurance system was reviewed. During a discussion the manager stated that thee had recently sent out “Listening Forms” to relatives/residents to complete in order to obtain feedback to improve care and other services provided within the home. Other tools used to monitor the quality of service include the key working systems, regular residents meetings, and regular newsletter with update on events and services to the residents and families. In addition the home operates an open door policy to enable the residents, relatives and visitors to have informal discussion on any area of concern. ‘Thank you’ letters from families were noted at the home. Regulation 26 visits by the registered provider are regular and had highlighted areas of concern, improvement and action to be taken in the last report sent to the Commission. The fire logbook is well maintained. There is evidence that staff have attended fire lectures however it was noted that of thirty-nine staff members only thirteen staff had attended fire drills on 23/03/06. The manager stated that a fire drill had been booked to take place on 23/06/06. A requirement was made to ensure that this is carried out. Accidents are recorded and followed up. Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 23 Policies and procedures in the home include, whistle blowing, complaints, Health and safety and Manual Handling Resident’s information and records were securely locked away Evidence from two staff records viewed showed that the staff have received regular supervision and the manager stated that various dates have been allocated for all staff to receive supervision. This will be reviewed at the next inspection Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 2 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 3 3 X X 2 X 3 Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 14/07/06 2. OP9 13 3. 4. 5. 6. OP36 OP15 OP38 OP27 17 (3) 16(2)(I) 23(4)(e) 23(3)(d) Each service user must have a care plan/action plan, which accurately reflects their needs and how they are to be met. Ensure that all hand written 14/06/06 medication on the MARS are singed and dated; All unwanted medication must be returned to the pharmacy for safe disposal; All controlled drugs must be accurately recorded in the MARS. All staff records must be 21/06/06 available for inspection. Review the menu to reflect residents choice and inform then when the menu is changed. Fire drills must be provided for staff. Deep clean or replace the carpets identified in two lounges. 14/07/06 23/06/06 14/06/06 Alexandra Way EPH DS0000035376.V299971.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. Refer to Standard OP9 Good Practice Recommendations Record all Controlled drugs in a bound book Alexandra Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Way EPH DS0000035376.V299971.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!