Inspection on 16/05/07 for Alexian Brothers Care Centre

This inspection was carried out on 16th May 2007.

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

Alexian Brothers Care Centre 08/04/08

Alexian Brothers Care Centre 16/10/07

Alexian Brothers Care Centre 11/05/06

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 Unannounced Inspection 16th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 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 3609 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.V336552.R01.S.doc Version 5.2 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. 13th March 2007 Date of last inspection Brief Description of the Service: The Alexian Brothers Care Centre is registered to provide accommodation for up to 62 older people. The home is owned by The Alexian Brothers, Province of the Sacred Heart and 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 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.V336552.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 13 March 2007 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the home prior to this visit as well as 7 returned resident comment cards. This unannounced visit forms part of the overall inspection process took place on Wednesday 17 May 2007. On the day of this inspection the Pharmacist Inspector also visited the home to undertake a pharmacist inspection. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also 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 talking with the home’s manager, several people living at the home, and some members of staff. Time was also spent observing how staff work with the residents, assessing relevant documents and files and a tour of the premises was undertaken. What the service does well: Alexian Brothers Care Centre continues to offer a high standard of décor, furnishing and a wide range of facilities and communal areas, which include a hairdressing salon, a consulting room for GP’s visits or other professionals, a physiotherapy gym and a large conservatory to the front of the building. There are large, well maintained gardens that are accessible to residents. A clean and pleasant environment id provided for the residents who live there. All received residents comment cards indicated that the home was usually clean and fresh, as did residents and a visitor spoken to during the inspection visit. A pre admission assessment of needs is carried out before a resident is admitted to the home to make sure that the home can meet their needs. The menus seen indicated that a wholesome, varied diet was provided and staff and residents spoken to confirmed that there was always a choice of meals at each mealtime and were complimentary about the standard of the meals. Staff said that if residents did not want what was on the menu the chef would prepare any reasonable request. All of the returned comment cards indicated that the residents enjoyed the meals and 1 comment received was Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 6 “The food we are served is excellent”. The staff said that residents could have drinks and snacks whenever they wanted. The visitor spoken to and all of the returned comment cards, with the exception of 1, indicated that residents knew how to make a complaint. One resident wrote we have notices on the door of each room which explains and if we needed any help with this the carers would willingly hep us. An open visiting policy was in place and the visitor spoken to confirmed that visitor were made welcome at any time. The relationships between staff and residents appeared to be very good. One resident spoken to about staff said. “The staff are lovely” and 2 comments received in the comment cards were “the patience of the carers here is to be admired and another comment was “their attitude seems to me to be one of availability. We are here for your. Their patience amazes me.” One visitor spoken to said that if she has ever asked to staff to do anything for her relative they have done it for her straight away. What has improved since the last inspection? What they could do better: At the last inspection visit it was identified that not all residents were getting their medication as prescribed by the GP and concerns were again identified at this inspection visit. For example medication for some residents had run out Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 7 and some was about to run and had not been reordered. If residents do not receive medicines properly their health could be at risk. To ensure the safety of residents sufficient nurses must be on duty, at all times, to cover meal breaks. To ensure the safety of the residents living at the home 2 written references must be obtained before any members of staff are offered work. Evidence was seen that staff were receiving training and staff spoken to confirmed that they had received training and that they were able to request training they felt they needed. However at the time of this visit there was no system for recording the training received and no system in place to assess that after the training staff were competent to be able to provide the support that residents need to meet their needs and maintain their health and safety. Although the home are in the process of recruiting an activity co-ordinator to meet the social and health care needs of the residents it is recommended that staff on duty carry out some activities, for example taking residents out into the garden when the weather is nice. The manager has been in post for over 7 months and to ensure the home is managed in the best interest of the residents living at the home she must submit her application as a matter of urgency. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 intermediate care is not provided at Alexian Care Centre). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs are assessed prior to them being admitted to the home to ensure that their needs can be met. EVIDENCE: A documented pre admission assessment form is in use to ensure that prospective residents are only admitted on the basis of a full assessment and evidence was seen that for residents who are referred through Care Management arrangements the manager obtains a summary of the Care Management Assessment. One pre admission assessment identified that the resident needed to be ventilated. On the day of this visit staff were receiving training on ventilation, Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 10 prior to the resident being admitted, to ensure that this resident’s care needs could be met. The recommendation made in the last report that the needs and preferences of people from specific minority ethnic communities or religious groups are assessed as part of the pre admission assessment to ensure their needs are understood and can be met by the home had been met because this was included in the death and dying section and the social outlook section of the pre admission document. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: Since the last inspection the care planning process had been reviewed and new documentation had been developed. Nurses employed by the home had undertaken a competency assessment in care planning. The new documentation was in the early process of being implemented and it was these care plans that were examined during this visit. They were seen to be improved and the files were better organised, which made them easier for staff to use as a daily as a working tool. However it was noted that the old care plans and the new care pans were both in the same file making it rather confusing. It is recommended that as soon as the new paperwork is implemented the old paperwork be immediately removed. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 12 Care plans included the pre-admission assessment, which identified the needs of residents. The new plans of care were found to contain be more detail, and set out the action that needed to be taken by staff to meet the personal care needs of the residents. Risk assessments had been included, however it was noted that the risk assessments relating to the use of bed rails did not address the risk of using the bed rail but only the risk of the resident falling from the bed. The manager said that the HMT Clinical Advisor was in the process of undertaking a bed rail assessment. Staff were observed delivering appropriate care and support to a number of residents in the home and it was evident from talking to the staff on the residential unit that staff had a good understanding of the residents individual care needs and treated them with respect and dignity. During the inspection the pharmacist inspector looked at records about medication together with the medicines held by the service to make sure that the requirements made at the previous inspection had been met and that residents were receiving their medication safely. It was found that no improvements had been made in the way medicines were handled since the last inspection and the five requirements made about medication had not been met. During the inspection it was found that medication had run out for a number of residents. An Immediate Requirement Notice was issued to make sure that medicine was made available for all residents immediately, to ensure continuity of treatment. The manager failed to obtain medicines for all but one of the residents on the day of the inspection and further failed to obtain the medicines for the following day The medicines, which had run out, included medication for asthma, diabetes, pain relief and nausea .The lack of continuity of treatment could put residents’ heath at serious risk from harm. It was also found that the records concerning medication were not accurate and the records could not be relied on to show that residents were getting their medicines properly. On some occasions it was seen that medication was signed for by the nurses but had not been administered to the resident. Also the nurses sometimes failed to sign the medication record sheets and it was not possible to tell from the records if people had been given their medicines or not. If nurses do not sign for medicines when they are given the resident could be given another dose of the same medicine, which could put their health at risk. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 13 It was also seen that not all the medication in the home could be accounted for. The nurses did not record accurately how much medicine was in the home at the start of the medication cycle and it was not possible to tell if medicines were properly accounted for by means of an audit trail. There were a number of examples when nurses did not give residents medicines as the doctor prescribed them. One resident was prescribed medicine for Parkinsonism and should have been given tablets five times daily at regular intervals. On three occasions during the month these tablets had been signed as given but were still in the blister pack and on four occasions the nurses had not signed the records sheets to show that the tablets had been given .On the day of inspection the tablet which should have been given at breakfast time was not given until 11.30 am. The poor administration of this medicine could cause the person harm to their health. It was also seen that another resident who was prescribed a strong analgesic patch to applied every 72 hours did not have the patch changed at the right times which left the resident without any pain relief on seven occasions during the past month for periods ranging between one and seven hours. This could cause distress to the resident and put their health at risk from harm. It was found that medicines were still being stored in areas of the home that were too hot to store medicines safely, this may lead to medicines not working properly and the health of residents receiving those medicines may be at risk. Nurses who were administering medicines had not been assessed as competent to give medicines properly. After the last inspection there were concerns that residents’ health was at risk because they did not get their medicines safely. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited activities were provided and residents were able to maintain contact with family and friends. Residents had a choice of varied, well balanced meals. EVIDENCE: It was encouraging that that the new care plan documentation included a social assessment and a care plan for socialising. The comments received in the comment cards and from the visitor varied from the home do provide activities to the home needs to provide more activities. The visitor said it would be nice if staff could just take the residents outside when the weather is nice. The manager confirmed that the home does need to provide more activities but explained that the activity co-ordinator has been off work for some time and the home were in the process of advertising for a temporary replacement until she returns to work. The manager said that the activity coordinary keeps a record of all activities and records of consultations with residents. However activities such as taking residents out into the garden or 1:1 activities should be undertaken by staff on duty on a daily basis. There is an open visiting policy and the staff and visitor spoken to confirmed this. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 15 From speaking to residents and staff it appeared that residents were encouraged to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home, as some of the bedrooms had been personalised with residents’ own belongings. The menu was on a 4-week rota, which had recently been reviewed and amended. The new menus examined demonstrated that the home provided a varied diet, which was nutritionally balanced and included adequate supplies of fresh fruit and vegetables. Each meal offered a variety of choices. Residents spoken to were complimentary regarding the quality and quantity of food and during this visit and residents were seen to be enjoying the lunchtime meal. Staff were seen offering assistance to residents, were required, in an appropriate and sensitive manner. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home had a complaint procedure and staff confirmed details about how to make a compliant are on the back of resident’s bedroom doors. The manager operates an open door policy and relatives/visitors, staff and visiting professionals to the home are encouraged to raise any concerns or complaints. The manager had files where all complaints are logged and details of the investigation and any action taken. Evidence was seen that staff had attended Protection of Vulnerable Adults (POVA) training and POVA training was being undertaken on the day of this visit. Staff spoken to confirmed that they had recently attended the training. The manager said that the homes policy relating to the Protection of Vulnerable Adults from Abuse had been reviewed and updated to accurately reflect the Adult Protection Guidance and each unit had a copy. Although this policy was not viewed on this visit. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, comfortable, well maintained environment was provided for residents. EVIDENCE: The accommodation is well furnished and is suitable for the residents living there. On the day of this visit the home was odour free and was found to be clean and tidy which created a pleasant environment for the residents and their visitors. As already stated in this report the home offers a variety of communal areas for residents to use and the garden area was well maintained and accessible to residents. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 18 The home provided adequate toilet and bathroom facilities. Toilets were conveniently located in close proximity to bedrooms and communal areas. A variety of bathing facilities were provided to meet a range of needs. During a tour of the building it was noted that the requirement made in the last inspection report that equipment must not be stored on the corridor had been met. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Shortfalls in the home’s recruitment and selection process could put residents at risk. EVIDENCE: At the time of this visit the home accommodated 59 residents. From examining the duty rota it appeared that the numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. However it was noted that the trained nurse on St Alexias went to lunch leaving 2 care staff and no qualified nurse on that unit. The nurse told the pharmacy inspector that she was going off the unit for lunch and asked her to give the unit keys to the nurse on St Joseph’s when she had finished with them, which is on the floor above. When questioned the manager said that normally there were 4 trained nurses in the building and the unit would be covered during lunch breaks but on the day of this visit due to training and holidays the cover was not available. The lack of nurse cover, during the lunch break, on this unit has the potential to put residents at risk. A small number of newly recruited staff files were examined. It was of concern that in 1 file only 1 reference had been obtained, the reference was addressed “to whom it may concern” and person completing the reference was not the identified referee name on the application form. In another staff file no references had been obtained. Both files did not contain a photograph of the Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 20 employees. This shortfall in the recruitment process has the potential to put residents at risk. The home employed 45 care staff, 5 of which had achieved NVQ Level 3 and 1 member of staff is currently undertaking it. Ten members of care staff had achieved NVQ Level 2 and 12 members of staff are currently undertaking it. In addition the manager said that 1 member of staff is currently doing NVQ Level 4 in care. Training was being undertaken for patient ventilation and POVA on the day of this visit and the manager described other training that had been undertaken which included Moving and Handling training, male catheterisation and a study day relating to stroke care. Staff spoken to confirmed that they had undertaken recent training for example POVA training. However there was no system for documenting training attended or evidence to show that staff competence had been assessed as to their understanding and application of knowledge gained through training events. The manager did not know what staff had attended what training and what further training was required for individual staff members. However she did say the since the last inspection the home had employed a part time training co-ordinator and the day after this visit had been scheduled for assessing the training and development needs of the staff. Although it was evident that training was being provided due to the lack of any documentation evidence could not be provided that all staff had received training and had been assessed as competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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. Not all areas of the home were managed in the best interest of residents. EVIDENCE: The manager took up post on 25 September 2006. At the time of this visit she was in the process of competing her application to register with CSCI. To ensure the home is managed in the best interests of the residents accommodated her application must be submitted as a matter of some urgency as she has been in post for over 7 months. Some areas of the home’s management were weak and did not promote the safety of residents. It was of particular concern that the issues identified in the last report regarding medication had not been effectively managed as no improvements were seen on this visit and residents were still placed at risk. In Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 22 addition it was of further concern that staff recruitment was not robust and placed residents at risk as staff were allowed to start work without references. The manager said that HMT have a quality assurance questionnaire that is sent out on an annual basis to residents, relatives and staff and then the manager is expected to produce a report based on the findings. However the questionnaire have not been sent out since the manager took up post. In addition a HMT Development Manager is due to undertake an audit of every department in the home and feedback will be given to the homes manager. In addition to the formal quality assurance programmes the residents views are obtained during the responsible individuals monthly visits and during resident and relatives meetings. The manager said at the last meeting in November 2006 residents and relatives requested that the meeting be held approximately every 6 months. Also the manager said she has an open door policy and encourages people to raise concerns or discuss any issues about the service being provided. The homes administrator has responsibility for resident’s monies. She had computerised records that were password protected. She had a running balance and she said that receipts were kept if anything was bought on behalf of a resident. Copies of invoices were seen. A bank account was available for 5 of the residents, records were seen of monies paid in and a balance for each resident and bank statements were also seen. However from the bank statement it was obvious that interest had accrued in the account and the administrator was unsure as to what happened to the interest. The operations manager confirmed that interest had been paid into the account and made assurances that the interest was still in the account. It is recommended that the interest accrued be appropriately worked out and divided between the residents in that account. Evidence was provided, in the AQUAA, that the home under took appropriate maintenance of equipment. Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 3 Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement Timescale for action 16/05/07 2. OP7 13 (4) (c) 3. OP9 13(2) - You must ensure that all residents have an adequate supply of medication to enable residents to have medication in exact accordance with the prescribers’ directions. This must be actioned before the next doses of medication are required. -You must send evidence that you have obtained medication for all residents whose health may be in potential danger without such medication. This evidence should be faxed to CSCI Manchester office within 24 hours of the inspection, which was dated 16 May at 14:15 hrs To ensure the health and safety 30/06/07 of residents, risk assessments relating to the use bed rails must be reviewed and further developed to adequately assess the risk of the actual use of the bed rail. 1. Accurate records must be kept 18/05/07 in order to provide evidence that residents’ recieved their medication as prescribed. DS0000066876.V336552.R01.S.doc Version 5.2 Alexian Brothers Care Centre Page 25 2. Medication must be stored at the temperatures specified by the manufacturers in order to ensure that residents receive medication in a good condition. 3. Medication must be administered in exact accordance with the prescribers’ directions and that there is an adequate stock of medication for each resident, in order to protect residents’ health and safety. 4. Medication must be accounted for at all times by means of an audit trail. 5. Only staff who are assessed as competent to administer medication safely must do so, in order to ensure that the health and welfare of the residents are met. (The previous timescale of 15/03/07 had not been met). 4. 5. OP27 OP29 18 (1) (a) 19 (1) (b) (i) Sufficient nurses must be on duty at all times to ensure that residents are not placed a risk. 1. To ensure the safety of the residents accommodated at the home 2 written references must be obtained prior to staff commencing work. 18/05/07 31/05/07 6. OP30 18 (1) (a) (c) (i) (ii) 2. Staff files must contain a recent photograph of the employee. All staff must receive appropriate 30/06/07 training and must be assessed as competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. DS0000066876.V336552.R01.S.doc Version 5.2 Page 26 Alexian Brothers Care Centre 7. OP31 8 The manager must submit her application to register with CSCI 21/05/07 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. Refer to Standard OP7 OP9 OP12 OP29 Good Practice Recommendations To avoid any confusion it is recommended that as soon as the new care plans are implemented for each resident the old care plan is immediately removed. It is recommended that the registered person monitor the temperature of the medication storage to ensure that all medication maintains stability and efficacy. To ensure that the social and health care needs of the residents are being met it is recommended that the staff on duty undertake various activities with the residents. 1. It is recommended that one reference is from the previous/most recent employer. 2. It is recommended that references addressed “to whom it may concern” are not accepted. To make sure that the home has a clear picture of all staff training needs it is recommended that they complete a review of training attended and develop a training plan based on the findings of the review. It is recommended that the interest accrued in the residents’ bank accounts be appropriately worked out and divided between the residents. 5. OP30 6. OP35 Alexian Brothers Care Centre DS0000066876.V336552.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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