Inspection on 29/06/05 for Alexandra Way EPH

This inspection was carried out on 29th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexandra Way EPH 10/07/07

Alexandra Way EPH 14/06/06

Alexandra Way EPH 08/03/06

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 AV 3 Alexandra Way Thornbury South Glos BS35 1LA Lead Inspector Jackie Hargreaves Announced 29 June 2005 09:30 th 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 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 AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Alexandra Way EPH Address 3 Alexandra Way Thornbury South Glos BS35 1LA 01454 866172 01454 866828 glenda-graham@southglos.gov.uk South Gloucestershire Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Margaret Kathleen Smith Care Hoem for Older People 40 Category(ies) of OP Old age for 40 registration, with number of places Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 9th March 2005 Unannounced 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 also having 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 AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out in one day over 10 hours and focussed primarily on the statutory requirements made at the previous inspection to assess the homes compliance with the Care Homes Regulations 2001. The manager was present throughout the inspection. A number of records were examined and discussed with the manager along with procedures and practices concerning admissions, care planning, staffing and management arrangements, training, and health and safety matters. Care plans and action plans for four residents were scrutinised in detail with the manager and changes noted from speaking with residents and in daily records checked against their action plan reviews. The inspector toured the premises and spoke informally with several residents, a relative and four staff in different areas of the home and on a more formal basis with two staff and four residents in private. Their views have been incorporated into the report. The Commission received a number of Comment/Feedback Cards from relatives and visiting professionals prior to the inspection. Their views of the home are also included in the report. Feedback was given to the manager on the outcome of the inspection. The home had addressed the 15 statutory requirements made at the previous inspection of the home in March 2005. There has been a period of instability in staffing and management arrangements. This has adversely affected clarity of leadership throughout the home and staff moral and has disrupted care planning and consistency of support to residents for activities and stimulation. This was reflected in the inspection process and in the views of residents and relatives who returned comment cards to the Commission. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? Considerable work has been undertaken by the manager and her assistants to address the statutory requirements made at the previous inspection in March 05. All, except those requirements relating to care planning have been fully addressed well within the specified timescales. Significant progress has been made on care/service delivery planning. Plans that provide comprehensive details about residents needs and enable staff to meet needs are being implemented. It is expected that the home will achieve full compliance with these requirements in the given timescales. The homes assessment and admission procedures for new residents has improved to ensure those involved are clear about what a resident needs and wants and admission processes, and to ensure that inappropriate placements are not made. The manager has put in place a staff training plan to ensure that all staff are provided with the required ongoing training to meet residents needs and to safeguard residents from abuse. The service has successfully recruited care and domestic staff, which should improve the continuity of services provided to residents, particularly those relating to activities to suit residents needs and preferences and provide stimulation. Work to the hot water system in the home has been carried out to ensure that hot water is regulated at a safe temperature for residents. Infection control measures had been improved upon to minimise cross infection and protect residents. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 7 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. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 standard(s) 2,3 Assessment and admission procedures are now of a good standard. EVIDENCE: The service had complied with a requirement made at the previous inspection to put in place an admissions policy and procedures to guide the staff team and to ensure residents were properly admitted. The home had also been supplied with a vacancy enquiry guidance chart and there was written criteria that identified the suitability of the home for meeting a persons specific needs. The inspector studied all of the paperwork relating to three residents most recently admitted to the home and discussed their admissions with the registered manager. This demonstrated that the home had followed the required procedures and had implemented good practice. Full up to date professional assessments of each residents needs and a care plan to meet their needs had been obtained prior to their admission and an admission questionnaire was completed with each person. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 10 The home had obtained background and other relevant information from each prospective resident and had undertaken an assessment of the persons needs for daily living in the home. Information was written in the first person which indicated the residents full involvement in the process. An action plan was in place detailing how the residents needs were to be met. A written review of a residents trial stay demonstrated that all parties had agreed to a permanent stay and that the home was suitable and able to meet the persons needs. One new resident spoken with about her experiences around entering the home confirmed that she was consulted throughout her admission and commented that staff had been, very attentive. Following a requirement made at the previous inspection the home had ensured that new terms and conditions of residency between the home and each resident that complied with the Care Homes Regulations were drawn up. The inspector looked at several of these documents. All had been appropriately completed by the home. Most were signed. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7,8 The home enables residents to access health care services. Positive outcomes for residents should be achieved with the improvements the home has made to care and service delivery planning. EVIDENCE: The previous inspection report required that each resident must have a care plan/action plan in place by 1 August 05 that accurately reflected their needs and how they were to be met. At this inspection there was good evidence that the staff team had worked hard to address this requirement and the manager expressed confidence that full compliance could be achieved by this date. Five files holding residents care/service delivery plans were closely studied. Four were fully up to date and detailed aspects of each persons personal, healthcare and social needs such as daily living, personal care, emotional/mental health needs, community/medical support, social/leisure interests, personal safety. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 12 Actions that needed to be taken to deliver the residents care plan were shown on a clearly detailed action plan. Four of five studied in detail were comprehensive, up to date, and included the required action specific to each residents need. The plans showed the person responsible for assisting the resident, time scales, outcomes of actions taken where applicable and review dates. Feedback from relatives and visiting health professionals was very positively noted in terms of satisfaction with the overall care provided to residents. Residents spoken with about the help they received from staff confirmed they were consulted on aspects of their care and that their wishes were respected. Comments included, nothing is too much trouble, I get the care and attention I want. Care planning notes demonstrated that health care services were accessed to meet residents health related needs and where a need required re-assessment by a health professional this would be addressed. It was noted in the homes previous inspection report that professional advice on continence was sought. As recommended, this advice should be included in planning for continence needs. A comment received as part of the inspection also indicated a need to ensure that all staff have knowledge about catheter care. There were no residents with pressure sores at the time of the inspection. Measures to prevent pressure sores occurring were not fully assessed on this occasion, however, it was positively noted that training in pressure care had been included on the staff training plan. Nutritional assessments, as recommended at a previous inspection, had still to be undertaken and this should be considered as part of the care planning approach to ensure residents nutritional needs are met. The inspector observed staff treating residents with consideration and respect when assisting and communicating with each person and this was reflected in the praise for staff from residents when discussing the ways personal attention and support was offered. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 standard(s) 12,15 Opportunities for activities and meals provided were not sufficient or consistent with residents needs and preferences. EVIDENCE: General discussions with residents and a relative confirmed that contacts with family and friends were promoted by the home and visitors were made welcome. Less evident from more formal interviews with four residents was demonstration of opportunities and resources to ensure that residents views regarding social and leisure interests and meals were being fully taken into account and acted upon. There was a full-time activities coordinator employed in the home and National Minimum Standards relating to activities was exceeded at a previous inspection. Residents and staff said that the activities coordinator had previously organised a full range of activities and, lovely trips. However, owing to staff shortfalls and demands on staff time, activities were fewer and some were not taking place. This was of particular concern regarding lack of regular stimulation and gentle exercise. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 14 Residents also reported disappointment with the quality of food provided. Three residents described the quality of food as not as good, not good enough, and needed to be improved. Specific reference was made to the quality of the main meal of the day and repetition of teatime meals. One person said that a snack was not always available in the evening after 6pm although drinks and biscuits were provided. Improvements needed to the quality and quantity of meals was also noted on feedback comment cards received from relatives. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 standard(s) 16,18 The service has an effective complaints procedure and there are robust protection processes that staff are being updated on. EVIDENCE: The homes complaints policy and procedures was available in the Statement of Purpose and included contact details of the Commission. A copy of the policy was displayed in each resident’s room to remind residents of their right to complain. A visitors book also enabled comments or concerns to be made about the home. In discussions with residents about their knowledge of the homes complaints procedures one resident said she knew how to make a complaint and had filled in a complaints form. Another person said she would not hesitate to make a complaint if necessary and would initially go to the manager. South Gloucestershire Council trains staff on the protection of vulnerable adults and supplies services with good policies and procedures to equip staff with knowledge of local procedures for identifying and reporting suspected and alleged abuse. At two previous inspections the service was required to ensure that full staff training on this topic was provided to enable staff to carry out their adult protection responsibilities. There was good evidence at this inspection to demonstrate that these requirements were being addressed. The staff training file showed that training for most staff on this topic was arranged for September and October 05. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,25,26 The home provides a comfortable easily accessible environment although some work is needed to improve the courtyard and consistency of attention is required to ensure all parts of the home are kept clean and hygienic at all times. EVIDENCE: Alexandra way is purpose built with accommodation on one level on corridors leading to an inner courtyard garden. The premises are suitable for the number of residents accommodated although future consideration could be given to making each corridor more distinctively recognisable to avoid confusion. The home is fully accessible to residents and is also wheelchair accessible. Overall, the premises were well maintained and generally clean and tidy on the day of the inspection although there was a slight odour and this was also commented upon in a comment card sent to the Commission. The manager advised that carpets would be cleaned to eliminate this. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 17 Four residents spoken with about their rooms and the general environment reported overall satisfaction, however, residents and a staff member made comments about the courtyard. It was said that this area, needed attention, had become less inviting, and, was not being used to its full capacity. Communal/shared space exceeds National Minimum Standards. Furnishings in these areas were domestic in style. Some armchairs need to be replaced. The manager had included these on a service plan. Improvements to the decor and flooring in some bedrooms had been carried out since the previous inspection. Independence aids were in place around the home and rooms were connected to the call bell system to enable residents to call for assistance at all times. Residents reported satisfaction with the system and the responses by staff to calls made. Toilet and bathing facilities were sufficient to meet the National Minimum Standards and residents needs. However, two residents expressed some concern about the cleanliness of toilets on occasions, which needs to be addressed, and about the lack of domestic staff. The shortage of domestic staff was confirmed in discussion with a domestic assistant on duty and the manager. The manager advised that the home had made successful efforts to recruit staff and three full time permanent domestic assistants should be in post in the near future to fill current vacancies. At the previous inspection the inspector required the service to ensure that the water distributed from hot water taps in service users rooms was at a safe temperature. The manager advised that temperature control valves had been fitted to washbasins. The distribution of hot water in two rooms tested safe at close to 43oC. There was evidence that requirements made in the homes previous inspection report referring to infection control and concerning aprons and bins in sluice rooms and procedures for handling soiled laundry had been addressed. Sluice rooms were properly organised to minimise cross infection and the manager advised that she had ensured staff were aware of infection control guidance and procedures. Infection control guidance had been made easily accessible to staff. During discussions with residents about the services they received several compliments were made about the homes laundry service, which was described as excellent, and perfect. The inspector spoke with the laundry person and saw that the laundry was well organised to ensure that a good personal service was provided. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 There is a competent and experienced staff team. However, there have been staffing shortages and breaks in staff training that are being addressed by the recent appointment of care and domestic staff and a training plan, which should ensure positive outcomes for residents. EVIDENCE: A requirement was made at the last inspection that appropriate staffing arrangements are put in place to ensure a sufficient number of staff are on duty at all times to meet the assessed needs of the service users. The home was adequately staffed on this announced inspection and the duty rota for the week beginning 27 June 05 showed a minimum of three staff on duty with four staff (minimum) at peak times. However, discussions with residents and talks with staff indicated that the home was still generally short staffed and care staff had been covering some domestic duties, which affected their ability to fulfil their caring roles. The manager and her temporary assistant on the day of the inspection advised the inspector that since the previous inspection recruitment of domestic and care staff had proved successful. This should ensure that the home has a full compliment of care staff, is maintained in a clean state, and residents social and leisure needs are met. There was evidence that guidance recommended by the Department of Health had been used for calculating ratios of care staff to residents? Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 19 There was a mature and experienced staff team. Staffing records showed that 19 care staff had worked at the home for over five years including 10 staff with at least ten years service. Relationships between staff members seemed good and supportive. A staff member said the home had a, good group of staff. Feedback from relatives on the quality of care provided by staff was very complimentary. Comments included, the quality of care has been outstanding, staff are always helpful and cooperative, staff do a first class job. 25 of care staff held NVQ level 2 in care or above. Records showed that 3 care staff had almost completed NVQ level 2 and several staff were working towards the award. All new staff received induction and foundation training that complied with National training standards. A staff training plan for 2005/6 was in place plus annual statutory health and safety training for each staff member with completion dates. The manager had arranged in house staff training to meet the specific needs of residents with dementia. This was ongoing and appreciated by staff. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,38 The health and safety of residents and staff is promoted, however, there has been instability in management staffing that that has been detrimental to effective leadership and disruptive to planning with residents to meet their needs and wishes. This is being addressed by the appointment of permanent staff. EVIDENCE: The homes manager, Mrs Margaret Smith, has been in post since February 05 and has applied to be registered with the CSCI. She is a registered nurse and NVQ Assessor and has previous management experience in care provision. Mrs Smith is currently studying for the RMA registered Managers Award (NVQ 4). Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 21 Prior to Mrs Smiths appointment the full management team was operating under temporary arrangements for well over a year. Although staff interviewed spoke positively about their work and expressed a strong commitment to the residents staff moral seemed to have been low because of the temporary nature of management and staff shortages. These concerns were also commented upon by residents and in feedback from a relative. The manager advised the inspector that two permanent assistant/duty managers had been appointed and the two temporary assistant managers were leaving their posts in another senior management change at the home. Residents said that meetings were not being held on a regular basis to enable residents to air their views. Two residents were concerned that the last meeting was cancelled with no notice and then reinstated following complaint. There was evidence of policies and procedures that reflected Health and Safety Regulations. Mandatory induction and follow up staff training on health and safety topics to promote the welfare and safety of residents was provided. The staff training file evidenced that several staff had received updated training in moving and handling. Updated food hygiene training had also been provided. 23 staff held up to date First Aid Certificates. The fire safety logbook was up to date. The last fire drill took place on 9 April 2005. Fire safety training was provided in April 2005, however, training for night staff was not fully up to date. A pre-inspection questionnaire supplied by the home for inspection purposes evidenced that equipment and health and safety checks were carried out. An Environmental Health Officer visited the home in November 04. Assessments for control of hazardous substances were undertaken. Accidents were recorded and incidents that affect the well being of residents reported to the CSCI as required. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 1 COMPLAINTS AND PROTECTION 2 3 x 3 x x 3 2 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 2 x x x x x 2 Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? 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 Each service user must have a care plan/action plan, which accurately reflects their needs and how they are to be met. Still within the timescale of 01.08.05 specified at the previous inspection. Care plans must be reviewed each month and evidence of evaluation recorded. Still within the timescale of 01.08.05 speficied at the previous inspection. The service must ensure that residents are regularly consulted about their social interests and that arrangements to enable residents to engage in local, social and community activities do not drop to an unacceptable level for residents or to a level that is not meeting their capacities or needs for stimulation and exercise Timescale for action 01.08.05 2. OP7 15 01.08.05 3. OP12 16(2)(m) 30.09.05 Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 24 4. OP15 16(2)(i) 5. 6. OP38 OP27 23(4)(d) 18(1)(a) The service must review the meals provided for residents to ensure that they are in adequate quantities, suitable, wholesome and nutritious, varied, properly prepared and available at such time as may be reasonably required by residents. Fire safety training must be provided for night staff. The service must ensure there are sufficient staff on duty at all times to meet the assessed needs of the residents. 30.09.05 30.10.05 30.06.05 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. 5. 6. Refer to Standard OP8 OP8 OP8 OP32 26 19 Good Practice Recommendations Continence promotion plans or action plans with clear details of professional advice on how continence needs are to be fully met should be developed. The service should ensure that all staff have knowledge about catheter care. Nutritional assessments for residents should be undertaken. The service should ensure that regular residents meetings are promoted and that residents views are sought and acted upon. The home should be kept clean and hygienic and free from offensive odours at all times. The home should consult with residents about the attention needed to the courtyard to make the area more inviting and more useable for residents. Alexandra Way AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 AV D56 D05 S35376 Alexandra Way V225366 290605 Stage 4.doc Version 1.30 Page 26 - 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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