Inspection on 08/03/06 for Alexandra Way EPH

This inspection was carried out on 8th March 2006.

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 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 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 Wendy Kirby Unannounced Inspection 09:30 8 March 2006 th 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.V261808.R02.S.doc Version 5.0 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.V261808.R02.S.doc Version 5.0 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 Mrs Jean Chapman Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 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. 29th June 2005 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 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 EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process. The duty manager was present throughout the inspection and a fellow colleague joined the inspection later in the afternoon. A number of records were examined and discussed with the duty managers, along with procedures and practices concerning admissions, care planning, staffing and management levels, training and health and safety issues. Four residents care plans were looked at in detail along with their profiles. The inspector was given a tour of the premises and spoke informally with several residents. Discussions were held with the cook and her assistant and the administrator. Feedback was given to both duty managers at the end of the inspection on its outcomes. What the service does well: What has improved since the last inspection? Residents now benefit from a varied activities programme, which is both enjoyable, stimulating and meets individual preferences and expectations. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 6 Residents now receive a varied and wholesome diet that they are able to influence. The residents have influenced the revamping of their courtyard, which has become an area they now wish to spend time in. The residents meetings are now held on a regular basis to ensure their views are sought and acted upon. The home is now clean, hygienic and free from offensive odours. 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 EPH DS0000035376.V261808.R02.S.doc Version 5.0 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.V261808.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 Prospective residents and their families are able to access clear information to enable them to decide whether the home is suited to their needs. Pre admission procedures demonstrated that resident’s needs were identified to ensure that the home would be a suitable place for them to live. Trial visits give prospective residents an opportunity to assess the nature of the home. EVIDENCE: Information on the home and the services offered was on display in the entrance to the home to take away. The information was well presented and included a statement of purpose, a user-friendly welcome pack, a copy of the latest inspection report and results of quality assurance surveys. The content of the welcome pack provided prospective residents with valuable information on the facilities and services available to them within the home. Prospective residents are encouraged to visit the home either for the day or perhaps for lunch dependent on their wishes. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 9 The Inspector looked at four pre-admission assessments, which were completed fully and were informative. The prospective resident, family and carers are involved in the pre-assessment and all information is used to determine the suitability of the placement. Where possible the manager had also obtained comprehensive assessments and care plans from other professionals involved for example, social workers and hospital staff. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 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 The service had good systems for meeting and monitoring residents’ health and personal care needs in consultation with residents, however plans must be developed to reflect these needs. There are safe systems of practice in receiving, storing, administering, and disposing of drugs. Staff have a good awareness of individuals’ needs and treat the residents in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. EVIDENCE: On admission to the home the resident is assessed over a four-week period and an action plan is developed whereby staff are able to identify a resident’s needs and wishes to determine plans of care. 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. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 11 Four residents records were looked at in detail, including preadmission assessments, care plans personal history profiles and risk assessments. All records showed evidence of consistency in assessing, planning, implementing and evaluating the resident’s care. Although evidence was seen of care records being reviewed monthly, some residents records were not indicative of their current health needs, for example the action plans had identified needs such as depression, potential risk of choking, diabetes, and psoriasis but there were not any care plans developed to identify what action would be taken to address these needs. Some of the content of care plans did not hold enough information and detail of the care/monitoring required, however the unit managers provided a copy of plans they had been recently looked at for developing within the home which will give more space for information and this aspect will be evaluated again at the next visit. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling, and the correct use of bed rails. Health Care needs were well evidenced in the Care Files and included records of the General Practitioner (GP) visits with residents and the outcomes were also documented. Specialist referrals and visits from other professionals including Chiropractors and Dentists and Opticians were also seen. The Inspector was informed that each resident was referred to a GP of his or her choice on admission to the home and an initial first visit was then set up. Although the GP does not conduct weekly visits to the home, good working relationships with the GP have been formed and they will visit on request. Personal history profiles on the residents were very useful and contained information about residents childhood, adolescence and adulthood. Standards for issues regarding safe practice in medication have been reviewed and developed since the previous inspection. Policies and procedures for receiving, storing, administering and disposing of medications were examined and correct. There were photographs of each resident on their medication charts to help ensure that medication was dispensed to the correct person. The administration charts were legible and continuity of administration was shown with a signature from the person dispensing. Information was also held for each resident on his or her medical conditions and preferred method of taking medication. Procedures for self-medicating were in place and risk assessments had been developed. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 12 Staff were witnessed knocking on residents’ doors before entering confirming respect for the residents’ individual privacy and dignity at all times. All rooms have a telephone point from which residents can make and receive calls. Private telephone lines can be installed. A portable pay phone is available and can be moved from room to room. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 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 Residents benefit from a varied activities programme, which is both enjoyable, stimulating and meets individual preferences and expectations. Residents maintain family contact and staff encourage family and friends to join in with activities and any outings. Residents receive a varied and wholesome diet that they are able to influence. EVIDENCE: From discussion with duty managers and the residents it was clear that the home has a flexible approach to residents wishes about the pattern of their day. Following the previous inspection the management, staff and residents have worked hard to introduce a varied activities programme based on a two week rota and have spent time on other details to improve the residents’ quality of life, which are detailed below. Due to previous shortfalls in staffing numbers activities and outings had been affected and residents expressed their disappointment at the previous inspection. New recruitment will help ensure that the residents’ needs will be met fully from now on. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 14 In the reception area there was a display of articles reminding residents and visitors of the fact that “Mothers Day” would be soon upon us. The display was fun and a simple but intuitive way of orientating the residents in time and place. The home now has a shop where residents can buy a range of useful day-today items, including toiletries, hosiery, small gifts, sweets and a selection of greeting cards to name but a few. Residents who are unable to access the shop either through poor health or mobility restrictions gain access to the shops content when staff take round the “trolley shop” Following a recommendation at the previous inspection, residents and staff made plans to improve the courtyard area. This has been replanted and shingled, with a water feature and bird feeders. There is plenty of seating in the area and in the summer the inspector was told that there was an array of colour from new hanging baskets. Activities are targeted to individuals who require one to one work as well as group activities. Residents are involved in activities such as gentle exercise to music, arts and crafts, and cake decorating and quiz games. Visiting entertainers include singers, concerts, and fashion shows where residents can buy new clothes. As the warmer weather arrives the home provides monthly trips to places of interest organised by the activities coordinator, these including Parks, garden centres, pubs and local events. Families will often accompany residents on outings. The home has monthly residents meetings, which are well attended and minutes, are taken and circulated to residents and their families on the notice boards throughout the home. Volunteers from the Red Cross visit the home fortnightly and assist with manicures for residents. Two members of staff have recently passed their test to drive the home’s mini bus, which will enable more residents to go further a field. The home operates an open door policy for visitors. Residents were able to see visitors in the privacy of their rooms and there were several semi-private seating areas around the home. Families and friends are also welcome to stay for lunch or tea to assist them with their visiting schedules. Due to staff shortages in domestic duties, kitchen assistants were deployed to clean the home. This had an effect on the staff resources in the kitchen and standards in the quality of food at mealtimes deteriorated. This was brought to the attention of the home at the last inspection and requirements were made. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 15 The home has now recruited domestic staff and the cook has her kitchen assistants back on duty. The inspector spent a short time with the cook and her assistant who stated that things were now improving. One duty manager is overseeing the need to meet nutritional needs adequately and in conjunction with the kitchen staff and residents they are devising a new five-week menu. The cook was able to demonstrate an awareness of individual requirements and needs of the residents, including special dietary requirements and personal preferences. The size and layout of the dining room made it possible for all residents to enjoy the social advantages of dining together. Staff had used their expertise and knowledge of the residents, personalities, preferences and ability to eat independently, when seating them for lunch. The dining room was light, spacious and the tables were attractively laid with tablecloths. Residents that required assistance with eating their meals were supported by staff members, this was performed in a respectful, sensitive way, for example without rushing the residents and staff were sat at the same level as the resident. Staff were seen to be polite and helpful when serving the meals The meal that day was liver and bacon, carrots, green beans and potato, followed by a milk pudding an alternative was also available. The inspector overheard one resident say “the meal was very filling”. The kitchen was clean and spacious. Stores exhibited a good range of foods. Food hygiene training was up to date for staff. Documentation was provided to show the inspector that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked, before serving. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 16 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): 16,18 A clear complaints process was in place and had been properly implemented in the home. Procedures to protect residents from abuse were in place and staff were made aware of the processes involved. EVIDENCE: As detailed in the previous inspection report the homes complaints policy and procedure is available in the Statement of Purpose and includes contact details of the Commission. A visitors book also enables compliments or concerns to be made about the home if required. There have been no complaints since the last inspection. South Gloucestershire Council trains staff on the protection of vulnerable adults and provides it’s services with good policies and procedures to equip staff with knowledge of local procedures for identifying and reporting suspected and alleged abuse. The majority of staff have now received this training and dates for April have been arranged for any staff who have not. There are procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse’. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 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): 19,20,21,23,24,25,26 The home is clean, comfortable, well decorated and furnished. It provides a safe, peaceful and a well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. One lounge carpet needs replacing. EVIDENCE: Alexandra way is purpose built with accommodation on one level on corridors leading to an inner courtyard garden. The home is fully accessible to residents and is also wheelchair accessible. The gardens were attractive and designed to the needs of the residents. The residents spoken with were very complimentary about the home and the garden areas. Room sizes are generally adequate for their stated purposes, particularly the lounges and dining room. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 18 Rooms are not en suite, however each resident has an individual commode and vanity unit with basin. Communal bathing areas, showers and toilet facilities are located throughout the home. All areas of the home were tastefully decorated, clean and well maintained. Attention has been given to ensure that all areas are homely. Residents had been supported to personalise their bedrooms with pictures and ornaments and residents are able to bring items of furniture should they wish. One resident was visually impaired and was particular about time keeping, two large face clocks had been put in her room so that she could see what time it was. One carpet in a lounge had been cleaned but the stains had remained, a requirement will be made to replace the carpet. Residents were making full use of these areas and their bedrooms on the day of the inspection. One resident stayed in her room all day, and the inspector had a talk with her in the afternoon. The resident explained that she had been a widow for thirty years and preferred her own company. The home was clean and free from unpleasant odours. The home now employs adequate staffing levels for domestic duties. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 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): 27,28,30 The residents are cared for by skilled staff that are trained and supported by management. The relationships between staff and residents are good and create a warm positive environment to live in. EVIDENCE: Since the previous inspection staffing levels are nearly at full compliment. A vacancy has become available for a full time carer and recruitment procedures are in process. Duty rotas were examined and correct levels had been maintained. There was a level of sickness, which required covering by regular bank staff and agency staff is used as a last resort. The inspector spent some time looking at the annual training plans and had a brief conversation with the duty manager who was responsible for ensuring training was up to date. The majority of staff had received mandatory training; dates had been arranged for any outstanding requirements and for staff updates. Training included the Protection of Vulnerable Adults, first aid, manual handling and food hygiene. Two duty managers are completing the National Vocational Qualification (NVQ) A1 assessor’s course, and the registered managers award. One duty manager is proficient in manual handling training. Seven care assistants have completed NVQ2 and seven are currently enrolled on the course. One member of staff has Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 20 enrolled on the NVQ2 in catering. The duty managers stated that they are initiating the next group of staff to commence either NVQ2 or NVQ3. The inspector spent some time throughout the day sitting in the communal areas observing staff carrying out their duties and assisting residents. Staff were respectful, warm in manner and sensitive towards the residents within a relaxed homely environment. The inspector spoke to several residents who expressed very positive views about staff and the care they receive providing comments like, “I love it, I really do”, “there’s always something to do and they look after me so well”. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 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): 32,33,34,36,38 Residents’ needs and best interests are central to the management approach in the home. Resident’s pocket money is safeguarded by sound procedures within the home Staff receive appropriate supervision. The health and safety of residents, staff, and visitors would be better protected if all night staff receive fire training. EVIDENCE: As mentioned previously in the report the inspector spent the duration of the visit with two fairly newly appointed duty managers. It was evident in conversations that both were dynamic in their roles and enjoying the new challenges that faced them. There shared various initiatives with the inspector to further develop standards and procedures in the home and both expressed how they were fully supported and encouraged by the unit manager. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 22 The overall outcome was that this fairly newly established management team and their staff were forging together in unison in order to provide a home with high standards for the benefit of all residents and staff. The policy and procedure for holding residents’ pocket money was examined and three individual accounts were looked at with the administrator. It was evident that good methods are adopted which account for all transactions documented and receipts for sundries were available to see. All three accounts checked had a correct running total. A monthly audit is carried out on all residents’ pocket money. Duty managers are responsible for allocated staff member’s supervision. The inspector looked briefly at the records maintained by two of the duty managers. Staff receive supervision once every eight weeks. Arrangements in place confirm that individual supervision is based on an agreement between the manager and staff member. A plan is devised for discussion relating to key residents, work issues, staff issues, personal development and training. The recorded outcomes of the supervision were comprehensive and evidenced the effectiveness of the sessions. Some of the Health and safety records in the home were examined. Documentation showed that all relevant checks were maintained correctly and at the required intervals including all fire alarms, equipment and emergency lighting. Fire safety training for staff is given on induction and then at the recommended given intervals. Some night staff require training and this must be provided within the requested timescale. The provider is completing monthly visits and copies of the reports are being sent to the Commission for Social Care Inspection. Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 3 X 3 X 2 Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 24 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 OP7OP7 Regulation 15 Requirement A) Develop Care plans which demonstrate holistic care and reflect the resident’s current needs accurately. B) Residents and/or their representatives must be involved in this process, wherever possible. Replace the carpet identified in the one of the lounges. Fire Safety training must be undertaken by all night staff. Previous Requirement Timescale for action 28/06/06 2 3 OP19 OP38 23(1) 23(4) (d) 07/04/06 07/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alexandra Way EPH DS0000035376.V261808.R02.S.doc Version 5.0 Page 25 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.V261808.R02.S.doc Version 5.0 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. 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. 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