Inspection on 11/05/06 for Alexian Brothers Care Centre

This inspection was carried out on 11th May 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 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

Alexian Brothers Care Centre 08/04/08

Alexian Brothers Care Centre 16/10/07

Alexian Brothers Care Centre 16/05/07

Similar services:

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Alexian Brothers Care Centre The Alexian Brothers Care Centre St Mary`s Road Moston Manchester M40 OBL Lead Inspector Geraldine Blow Key Unannounced Inspection 11th May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 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. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alexian Brothers Care Centre Address The Alexian Brothers Care Centre St Mary`s Road Moston Manchester M40 OBL 0161 681 1929 0161 947 3699 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) The Hospital Management Trust Care Home 62 Category(ies) of Old age, not falling within any other category registration, with number (62) of places Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of service users aged 60 years or over accommodated at any one time shall not exceed 62. A maximum of 46 service users assessed as requiring nursing care, of either sex, aged 60 years or over may be accommodated. Date of last inspection 21/11/05 Brief Description of the Service: The Alexian Brothers Care Centre is registered to provide accommodation for for up to 46 older people assessed as requiring nursing care for up to 16 older people assessed as requiring personal care only. The home is owned by The Alexian Brothers, Province of the Sacred Heart. However since the last inspection the Hospital Management Team (HMT) have been registered with the Commission for Social Care Inspection (CSCI) to assume full management responsibility for the Care Centre. The Alexian Brothers still own the building and a community of Brothers live on site but the overall day-to-day management is undertaken by the HMT. The home is located in the residential area of Moston in the North of the city centre of Manchester. Public transport links into Manchester City centre are within easy walking distance. There are ample parking facilities at the front of the building. The home is a three storey purpose-built building set in its own spacious grounds. Accommodation for the residents is provided on three floors and is accessible to residents who use a wheelchair. All bedrooms are single and 48 are fitted with en-suite facilities. A variety of communal areas are available for residents including a chapel with daily services. The home is divided into 3 units. There are 2 nursing units and one unit providing personal care only. The residents have a choice of lounges and dining rooms as the home provides several alternatives. The furnishings and décor throughout the home were found to be of a high standard. The residential unit provides a kitchen for resents and relatives/friends to make drinks or snacks at any time. Each unit provides a smoking room. The home has ample, well-maintained grounds. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, conducted by 2 inspectors and took place on Thursday 11 May 2006. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS) and was used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent with the residents who live at the home, observing how staff work with residents, discussions with staff and the manager and the deputy manager, assessing relevant documents and files and a tour of the premises was undertaken. Since the last inspection the day-to-day operations of the home have been taken over by The Hospital Management Trust (HMT). The HMT has the specific aim of retaining the founding ethos of charitable and religious hospitals and homes while ensuring ongoing development of the services needed to keep pace with modern medical and nursing practice. A new manager took up post on 3 January 2006 and has attended an interview with the Commission for Social Care Inspection (CSCI) for registration. A pre-inspection questionnaire was sent to the home before the inspection but it was not returned to CSCI before the inspection. The last visit to the home identified a number of areas that the home needed to improve to meet the NMS. The home had sent the CSCI an action plan setting out how they were going to address these issues. It was found that progress had been made in some of the areas. The CSCI had not received any complaints or concerns about the home since the last visit. What the service does well: The home continued to provide a high standard of décor, furnishing and facilities. As identified at the last inspection the standard of cleanliness throughout the home continued to be high. One relative spoken to said, “the home is always spotlessly clean”. The home carries out assessments before a person is admitted to the home to make sure that the home can meet the person’s needs. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 6 Each resident is registered with a General Practitioner (GP). A GP visited the home five days a week and had their own consulting room where residents were seen. Residents could also see their GP in the privacy of their own room if they wanted to. The relationships between the residents and staff appeared to be very good. Staff were seen talking and joking with residents and the residents were seen laughing and joking with each other. One resident said, “the staff are really nice”. From observations and talking to staff and residents it appeared that the privacy and dignity of residents was protected. The home had an open visiting policy and residents spoken to said that they could have visitors at any time. The manager and the staff spoken to said that residents are helped to make choices and have control over their daily lives, unless an activity posed a risk to the residents care, residents spoken to agreed with this. A choice of food is available at each meal time and if residents don’t want what is on the menu they can have any other reasonable request, like cheese on toast, an omelette or a sandwich. The residents’ spoken to were happy about the quality, choice and quantity of food. Staff were seen helping residents at mealtimes. The kitchen was clean, well organised and all food was seen to be appropriately stored. There were large stocks of food including fresh fruit and vegetables. The home encourages and support care staff to undertake NVQ Level 2 and Level 3 training. At the time of inspection 20 staff members had successfully completed Level 2. What has improved since the last inspection? Since the last inspection the qualified nurses had had care planning training and the home are planning to provide similar training for the care staff. The HMT and the new manager have reviewed the paperwork that was used for the care plans and have put a new system into place. The new paperwork is detailed yet easy for staff to fill in and use. The staff spoken to said that they liked the new paperwork and found it easy to use. It was commendable that the home has put in place a ‘Dependency Assessment Tool’ that is filled in every month to ensure that enough staff are being provided to meet the needs of the residents accommodated. Since the last inspection the times of staff shifts have been changed and the staff spoken to said the new times are better as there now more staff on at meal times. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 7 The home have recently employed a full time activities co-ordinator and activities such art, movement and music and baking have taken place. A summer fete was in the process of being organised. The home had held a party on St Patrick’s Day and St Georges Day, which the staff and residents enjoyed. At the last inspection it was required that all new members of staff must have the appropriate safety checks to be able to work with the residents and this requirement had been met. The HMT had employed the services of a design team who were in the process of reviewing the furniture and soft furnishings of the 2 communal areas on both floors of the home and 7 of the bedrooms. What they could do better: Although the new paperwork for the care plans had been put into place it was seen that not all sections of the plans had been completed. Due to this shortfall the plans of care did not set out in detail the actions which needed to be taken by staff to ensure that all the health, personal and social care needs of the residents are met. Also evidence could not be provided that the plans of care had been drawn up with the involvement of the resident or their relatives. The systems and procedures for dealing with medicines still needed improvements to protect residents. For example, some prescribed medications had been given to the residents but had not been signed for and on 1 occasion a controlled drug, that must be signed for by 2 nurses, only had 1 signature. The manager was not able to find the adult protection procedure and the staff spoken to told the inspector that they had not received any training on what action to be taken in the event of an allegation of abuse. This has the potentional to put residents at risk. The adult protection procedure must be available to all staff and contain the correct telephone numbers for making a referral. Providing staff with the necessary training is important to make sure that the residents needs can be properly met. Evidence could not be provided of all staff training or that all staff had been through an induction process. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 8 During the inspection a number of fire doors were seen to be wedged open and a large number of wheel chairs were stored on the corridor outside the resident bathrooms and toilets. This poses a risk to the health and safety of staff and residents and alternative storage space must be found. 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. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 9 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 Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 10 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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: A pre-assessment form was in use, to ensure prospective residents are only admitted on the basis of a full assessment. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. However the recommendation made at a previous inspection that the needs and preferences of people from specific minority ethnic communities or religious groups are assessed as part of the preadmission assessment to ensure their needs are understood and can be met by the home had not been met and has been reiterated in this report. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 11 For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The home does not provide an intermediate care service Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 12 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 Each resident had an individual plan of care. However, some areas of the plan required improvements to ensure residents’ health, personal and social care needs are fully met. The systems and procedures for dealing with medicines needed some improvements to protect residents. EVIDENCE: The home had worked hard to review and implement the new care planning process. The new paperwork was detailed, comprehensive and risk assessments had been included and evidence was seen that monthly reviews had taken place. Part of the plans are pre-printed and include a tick box style assessment. However, on a random sample of care files inspected it was seen that not all of the tick box’s had been completed and additional information had not been documented in the box provided. Due to this lack of documentation the plans were vague and did not set out in detail the actions Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 13 staff needed to take to ensure that all aspects of care are met. Part of the documentation included a sheet to evidence resident/relative involvement of the drawing up of the care plan. However on the files inspected this sheet had not been completed. It is appreciated that the new system is newly implemented and the content of the care plans will be thoroughly inspected at the next inspection. The manager told the inspector that the home had been working closely with the PCT pharmacist in an attempt to improve the systems within the home and that during April 2006 the home had employed the services of a new dispensing pharmacist. Medication records were examined during this inspection and it was found that there were a number of gaps in the recordings of medication. On checking the stock level it was found that the medication had been given in those instances but not signed for. Several prescribed creams had not been signed for as given and as a result it was not possible to ensure that the residents had received the required medication and this could impact on residents health care. On a number of MAR sheets it was documented “none supplied this month ”. The explanation given by the manager was that the residents no longer required the medication so the home had not ordered it. However the system is confusing and it is recommended that the home liaise with the dispensing pharmacist to discuss the matter. On examination of the controlled drug register it was noted that on 1 occasion a controlled drug had been given and only signed by 1 member of staff. The administration of controlled drugs must be witnessed by another designated appropriately trained member of staff. Medication with a limited life must clearly document the date of opening to ensure out of date medications are not given to residents. The date of opening had had not been documented in all cases, therefore not protecting and safeguarding the residents health. The manager said that there was an up to date list of staff signatures who were responsible for administering medication, however it could not be found. For the purposes of accountability the home should have this list. In line with the Royal Pharmaceutical Guidelines the home received the prescritions and signed the exemption declaration on the back of the prescription prior to them being submitted to the pharmacy for dispensing and a copy of the prescription is kept by the home. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 14 From observations made during the inspection and discussions with members of staff and residents, it appeared that the nurses and care staff treated the residents with respect and dignity. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 15 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 good. This judgement has been made using using available evidence including a visit to this service Activities were provided and residents were able to maintain contact with family and friends and they were able to exercise choice and control over their lives. EVIDENCE: The home had recently employed a full time activities co-ordinator. The preadmission assessment had a section relating to work/play and social outlook and the new care plan documentation had a social assessment tool and a record of activities attended. Staff who were spoken to said that residents were encouraged to participate in activities in the home and were enjoying the activities. The activities co-ordinator was not available on the day of inspection but the manager said that she did consult the residents regarding the activities they wished to undertake and documented this information, although the information could not be viewed by the inspector. As already stated in this report plans for a summer fete were being discussed and it was commendable that residents and relatives where involved in this process and some relatives had agreed to run a stall on the day of the fete. The manager said that the home has a strong community contact and on a daily basis, after Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 16 mass, coffee and biscuits are provided for residents and people from the local community are encouraged to attend. The home had an open visiting policy and visitors could be received in the residents’ own room or any of the communal areas of the home. Residents and staff spoken to during the inspection confirmed this. From speaking to residents and staff it appeared that residents are able to exercise choice and control over their lives. Evidence was seen that residents are able to bring personal possessions into the home. The home has an ‘Advocacy Policy’, which contains a list of contact addresses and phoned numbers. This is kept at the main reception desk and available on request. The menus had been developed on a 3 week rota in accordance with residents likes and dislikes and appeared to offer a varied, wholesome and nutritious diet. There was an option on the menu for ordering small or medium sized portions and the chef confirmed that he regularly catered for individual tastes. For example, 1 resident liked to have a kipper for breakfast so this was prepared daily for him. The chef also confirmed that if residents did not want any of the choices on the menu he would prepare something else of their choice. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The home has the systems and procedures in place that allow people to express their complaints/concerns. However, people are not fully protected due to the staff not having undertaken the relevant training. EVIDENCE: The home had a complaint procedure, which was also incorporated into the Service User Guide. The home had received 1 compliant since the last inspection that appeared to have been appropriately investigated. The manager had a record of the complaint, which included details of the investigation and staff statements. The resident spoken to said that she had never had to make a complaint. Although the manager said that the home had policies and procedures relating to the Protection of Vulnerable Adults and had access to the Manchester MultiAgency Adult Protection Procedures they could not be found. In addition, the home supports residents who are placed by different local authorities and they did not have the necessary contact details for making adult protection referrals. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 18 The adult protection procedure must be easily accessible at all times and contain the information relevant for making referrals to the appropriate local authority. The manager said that not all staff have received adult protection training and this was confirmed by the staff spoken to. In order to protect the residents living at the home all staff must receive Protection of Vulnerable Adults Training, which includes the actions to be taken in the event of an allegation of abuse. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 19 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 & 26 Quality in this outcome area is good. This judgement has been made using using available evidence including a visit to this service The premises are comfortable, safe and the homes environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: The home provides large, attractive, well maintained grounds with a variety of garden areas which are accessible to residents in wheelchairs. The home felt comfortable and homely and all areas of the home were exceptionally clean. The home was tastefully decorated and furniture was of a domestic nature and of a high standard. As already stated in this report a design team have been employed to review 7 bedrooms and the communal areas on both floors of the home, which includes furniture and soft furnishings. Resident’s bedrooms were seen to be comfortable and personalised. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 20 During a tour of the building it was noted that the sluice door had been propped open and a large number of wheel chairs were stored on the corridor outside the residents bathrooms and toilets. These pose a significant risk to residents and the sluice door must be kept locked when not in use and the wheelchairs must be stored more appropriately. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service The number and deployment of staff available appeared sufficient to meet the residents’ assessed needs. However, the home was unable to demonstrate that its staff had completed the required training to meet resident’s needs although the procedures for recruiting staff were not robust and must provide adequate safeguards to protect residents. EVIDENCE: On the day of the inspection the staffing numbers and skill mix appeared appropriate to meet the needs of the residents accommodated. As already stated in this report a dependency assessment tool had been implemented in an attempt to ensure that sufficient staff are employed to meet the needs of the residents’ accommodated. Since HMT have taken over the staff shift times have been reviewed and changed. The staff spoken to said the new times benefit the residents as there are more staff on at meal times. The home employs 35 carers, 19 members of staff have successfully achieved NVQ Level 2 and 1 had achieved NVQ Level 3, in addition 6 members of care staff were part way through NVQ Level 2 training when the company went into liquidation and the manager was noted to be in the process of finding an alternative NVQ provider to facilitate the training. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 22 Evidence was seen that newly appointed staff went through a structured induction process. Staff spoken to did say that they were receiving training, however they did not have an individual training and development programme and documented evidence could not be found to support this in all cases. A random sample of staff files were inspected. It was seen that CRB and POVA checks had been undertaken and that staff had a contract of employment, that included the information required at the last inspection. It was noted in 1 file that the employment history demonstrated a 3-year gap in employment but no evidence was available to demonstrate that this gap had been explored and the same file contained only 1 reference. To ensure the safety of the residents all gaps in employment should be explored and the reasons documented further to this the provider must ensure that 2 written references are obtained Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 23 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The home has the systems in place to monitor the service based on the residents views. Not all areas of the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The acting manager took up post on 3/1/06. She is a RGN who has had previous experience in management positions. The Manager has attended interview with CSCI for registration. HMT have produced a quality assurance questionnaire. The questionnaire has been sent to all staff who then send the completed anonymous questionnaire back to HMT who have analysed the results, which have been sent to the Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 24 manager. HMT are due to send the manager questionnaires to distribute to residents, relatives and visiting professions in order to gain they view of the service provided. The manager said it was then her intention to produce an action plan based on all the results. HMT have reviewed and updated all the homes policies and procedures. The folder containing all the policies and procedure is kept at the man reception desk for all staff to access. The administrator who is responsible of residents’ money was unavailable on the day of inspection and her computerised records were password protected. The manager explained the procedure and that a running balance and receipts were kept. This will be thoroughly inspected at the next inspection. Secure facilities were provided for any money or valuables held on behalf of residents. During a tour of the building it was noted that a number of residents bedroom doors had been wedged open. Fire doors must not be wedged open as this causes a risk to staff and residents. The home was maintaining an accurate fire log with the required checks and fire drills. Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 26 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 1.The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed for by the resident whenever possible and/or their representative. (The previous timescale of 31/7/05 and 31/12/05 had not been met). 2. The residents’ plan of care must set out in detail the actions which need to be taken by staff to ensure that all aspects of health, personal and social care needs are met. (The previous timescale of 31/12/05 had not been met). 2 OP9 13 The Registered Person must make arrangements for the recording, handling, safekeeping and safe administration of medicines which are detailed below: DS0000066876.V293851.R01.S.doc Timescale for action 30/06/06 30/06/06 Alexian Brothers Care Centre Version 5.1 Page 27 3. OP18 13 The person administrating them must sign for all prescribed medication. • The administration of controlled drugs by authorised staff members must be witnessed by another designated appropriately trained member of staff. • Medication with a limited life must clearly document the date of opening to ensure out of date medications are not given to residents. 1. The adult protection procedure must be easily accessible at all times and contain the information relevant for making referrals to the appropriate local authority. 2. Evidence must be provided that all staff have received Protection of Vulnerable Adult training which includes the actions to be taken in the event of an allegation of abuse. Equipment must not be stored on corridors as this could causes a potentional tripping hazard To ensure the health and safety of residents the sluice door must be kept locked when not in use Two written references must be obtained for each employee Evidence must be provided that all staff have undertaken the necessary training in order for the home to ensure that it provides suitably qualified, competent and experienced staff to ensure that the health and welfare of the residents are met. To ensure the health and safety of residents and staff are DS0000066876.V293851.R01.S.doc • 30/06/06 4. 5. 6. 7. OP19 OP26 OP29 OP30 13 13 17 Schedule 2 18 11/05/06 11/05/06 30/06/06 31/07/06 8. OP38 13 & 23 11/05/06 Page 28 Alexian Brothers Care Centre Version 5.1 protected at all times the responsible individual must ensure that fire doors are not be wedged open. 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 OP3 Good Practice Recommendations It is recommended that that the needs and preferences of people from specific minority ethnic communities or religious groups are assessed as part of t he pre-admission assessment to ensure their needs are understood and can be met by the home 1. It is recommended that the manager liaise with the dispensing pharmacy regarding the MAR sheet containing reference to drugs not prescribed by the GP 2. It is recommended that the home have a list of staff signatures who are responsible for administering medication All gaps in employment should be explored and the reasons documented. 2. OP9 3. OP29 Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Alexian Brothers Care Centre DS0000066876.V293851.R01.S.doc Version 5.1 Page 30 - 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!