Inspection on 08/04/08 for Alexian Brothers Care Centre

This inspection was carried out on 8th April 2008.

CSCI found this care home to be providing an Poor service.

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 16/10/07

Alexian Brothers Care Centre 16/05/07

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 171 St Mary`s Road Moston Manchester M40 0BL Lead Inspector Sue Jennings Unannounced Inspection 8th April 2008 09:30a 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.V361485.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.V361485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexian Brothers Care Centre Address 171 St Mary`s Road Moston Manchester M40 0BL 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) 0161 681 1929 0161 947 3609 The Hospital Management Trust Amanda Froggatt Care Home 73 Category(ies) of Old age, not falling within any other category registration, with number (73) of places Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with Nursing - Code N to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 73. 12th March 2008 Date of last inspection Brief Description of the Service: The Alexian Brothers Care Centre is registered to provide accommodation for up to 73 older people. The home is owned by The Alexian Brothers, Province of the Sacred Heart and the Hospital Management Trust (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 three units. There are two 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 residents 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.V361485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. Two regulatory inspectors and the pharmacist inspector carried out the inspection. The visit was unannounced and took place over the course of 8.5 hours on Tuesday, 8th April 2008. During the course of the site visit time was spent talking to the manager, the cook, five day staff and six of the residents to find out their views of the home. Time was spent examining records, documents, the residents files and staff recruitment records. Fees for accommodation range from £375-00 - £480-00. There is an additional top up fee. There are additional charges for hairdressing, newspapers and toiletries. What the service does well: People thinking about moving in were invited to visit and spend time with the residents. As stated in the last inspection report, the relationships between staff and residents appeared to be very good and the residents spoken to confirmed this. Residents said “they look after me well” and “the staff are very helpful”. Staff reported that the management team were “very supportive and very helpful”. Residents said the food is “very tasty and there is always a choice”, “my family is made to feel welcome”, “I have everything I need here and nothing is too much trouble for the staff”. Staff were observed to treat residents with respect. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 6 The environment is maintained to a high standard. The home meets the religious and spiritual needs of residents who are of the Roman Catholic faith. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 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 Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has systems in place to make sure that people’s needs are assessed before admission. EVIDENCE: Prospective residents were able to visit the home before making a decision to move in. Where this was not possible families were invited to visit on their behalf. One resident said “my daughter came and looked at the home for me”. Another said, “I could not come but I spoke to the hospital Chaplin and he said it was a lovely place”. The home had a Statement of Purpose and Service User Guide which gave prospective residents and their families information about the home. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 9 As stated in previous reports a documented pre-admission assessment form is in use. One of the managers visited prospective residents in his or her own home or in hospital to carry out an assessment before admission. This is done to make sure that people are only admitted on the basis of a full assessment. Residents placed by the local authority had a care manager’s assessment of needs. Alexian Brothers Care Centre does not provide an intermediate care service. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. Care plans were not sufficiently detailed and poor medication practices had the potential to place residents at risk of harm. EVIDENCE: We saw a sample of care plans and although the organisation had developed a new care plan format some residents did not have completed care plans. We saw that other old style care plans had been removed and some care plans contained blank sheets. Where care plans had been completed they did not clearly identify residents care needs and therefore could not give clear direction to staff on how to meet needs. To ensure that the health care needs of residents are fully met the individual plans of care must contain more detail and specific direction for staff on how to meet residents identified care needs. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 11 The pre-admission assessment section of one resident’s care plan gave some good person-centred information. This showed that the resident had been involved in the assessment but this information was not then used to write the actual care plan. This means that the residents may not be receiving care in line with their wishes. We saw no other evidence to show that residents are asked about the way personal care is delivered. Some care plans gave conflicting information. For example, the nutritional assessment on one care plan showed the resident as being at moderate risk and the guidance stated weight should be monitored weekly. The nutritional care plan stated, “weight to be monitored monthly”. This means that the residents weight was not being recorded appropriately. We also saw that information relating to one resident was held in a file with another residents name on it. Where residents have a nutritional assessment highlighting the need for weight monitoring an accurate record of weight must be kept in order to identify when referrals to specialists are needed. The daily records in another care plan stated ‘positional changes maintained’ but there was no care plan detailing what positional changes are. To make sure that residents’ care needs are met all positional changes charts must be accurately completed to reflect the care given. This enables staff to monitor residents who are at risk of developing pressure areas and to access medical support as soon as possible should it be needed. Where a risk is identified during the assessment process a risk assessment must be completed and held in the care plan for staff to reference. We saw one care plan where the resident had specialist dietary needs and had been visited by a dietician. The dietician had recorded clear instructions on how to care for the resident’s feeding tube (PEG) site. We saw no evidence that this advice had been acted upon. Where residents have been assessed as needing PEG feeds the advice of the dietician with regards to care of the PEG site must be acted upon and clear records kept. We saw that health care issues were not being adequately recorded within individuals care plans and there was little or no evidence that regular health monitoring takes place. In order to evidence that the identified needs of the residents are being met a record of the resident’s condition and any treatment given must be kept. We saw that short-term care plans had been developed for specific treatments but they were not removed from the care plan even though the treatment was completed and the review date passed. This indicates that care plans had not been reviewed. To avoid confusion it is recommended that the care files are reviewed and all out of date information be removed and filed in a secure and orderly fashion. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 12 It was of concern that the care plans of one resident who does not take any food or drink by mouth showed that sometimes they ‘ate for the pleasure of eating’. It was also of concern that the nurse caring for them was not aware of this and no risk assessments had been completed. All residents must have a care plan that clearly identifies care needs and contains sufficient detail for staff to meet all residents identified needs. It is strongly recommended that that all residents care plans are developed using a person centred approach. During the inspection the pharmacist inspector looked at how well medicines were handled to make sure that residents were being given their medicines properly. The records regarding medication continued to be poor and failed to show exactly what medicines had been given to residents. They also failed to show that all medication could be accounted for. When some medication was received into the home it was not properly recorded so it was difficult to audit or to check if this medicine had been given properly. It was worrying that when management audits of medicines had been carried out they were unaware of the amount of some medication in the home, and that the audits could not be relied upon to show that medicines were given properly. Stocks of some medication did not correspond with the medication administration records. This raised concerns that the receipt and disposal of medication were not being accurately recorded. Despite an immediate requirement being issued at the last key inspection we continue to have serious concern that not all residents were getting their medication as prescribed by the Doctor. This could put the residents’ health at serious potential risk Some residents could not have their prescribed medication as it was not available in the home. Another resident was visited by their GP who prescribed an antibiotic. This antibiotic was not given to the resident until six days later; this could have put this resident’s health at serious risk. The medication administration records also indicated that a resident could have been given too much Paracetamol. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 13 We was also had further concerns that controlled drugs for several residents who were no longer living there were still in CD cupboard. It is important that medication, which is not longer needed, is disposed of safely and in accordance with policies to prevent any risks of mishandling. We found that some eye drops, which were in use on the day of inspection, were not dated to show when they were opened and some were not stored at the correct temperature. This means that residents could be given prescribed eye drops that were beyond their expiry date, which could damage residents’ eyes or were ineffective due to poor storage. We saw staff interacting well with residents. We spoke to residents and they told us they were happy with their care and that staff respected their privacy and dignity. One resident said “I am quite content to sit here with the music and my paper, the girls bring a paper for me in the mornings and I get an evening news at night”. Another said “Very happy with the home, and when asked she said that “you can have a drink whenever you want” and “Staff are good and always helpful and kind”. One resident said “I would say it really is a lovely place they look after us very well, it is perfect in every way”. Alexian Brothers Care Centre DS0000066876.V361485.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 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents are able to maintain their religious beliefs. Activities are provided and residents are able to maintain contact with family and friends. Residents have a choice of varied, well-balanced meals. EVIDENCE: The home has a large chapel which is used by neighbours and other members of the community; this indicates they have good relationships with members of the public. Residents told us they were able to maintain their religious beliefs and attend mass in the chapel. Those residents unable to attend the mass can watch the service in their bedroom via a television channel. One resident told us “I watch the service on TV it makes me feel closer to God and that is important”. Another said “I listen to the mass each day”. Routines are very flexible and residents can make choices in all areas of their life. They told us that admission to the home is not restricted to Roman Catholics. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 15 Staff were observed giving assistance to residents who needed support during mealtimes, including those who have difficulty swallowing or chewing. Mealtimes are flexible and relaxed, staff are patient and helpful, and allow people the time they needed to finish their meal comfortably. We saw the menus they were varied and balanced and cater for the varying dietary needs of residents. The dining areas were bright and inviting. There is an activities organiser and a weekly programme of activities was displayed in the entrance area of the sun lounge on the residential unit. Activities include board games, visiting entertainers, video shows, planting seeds and knitting. Residents were able to participate as they chose in any activities. Staff respect any decision made by residents in relation to participation of activities. We saw five residents sitting in the sun lounge watching an old film and they told us that this happens regularly. They told us that a relative support group meeting had taken place the previous evening and that this was well attended. Alexian Brothers Care Centre DS0000066876.V361485.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has policies and procedures in place to safeguard residents from abuse and people are confident that their complaints will be acted upon. EVIDENCE: Copies of the complaint procedure were seen on the back of residents’ bedroom doors. There are suitable procedures in place for dealing with complaint’s. The complaints policy and procedure is part of the guide for the people living there. One resident told us “I have nothing to complain about they are very good”. There is an ongoing staff training programme that includes safeguarding adults. We asked staff what they would do if they witnessed an abusive situation and they told us that they would “immediately report it to the manager”. They told us that they had “missed the last POVA training but I am down for the next one”. Alexian Brothers Care Centre DS0000066876.V361485.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 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The premises are safe and the home’s environment, including the standard of hygiene, was well maintained both internally and externally. EVIDENCE: We saw a sample of resident’s bedrooms and saw that residents had brought some personal belongings with them. All rooms seen were found to be clean and tidy and nicely decorated and those residents spoken to said that they were very happy with their rooms. We saw eleven new bedrooms. All have an en-suite toilet and washbasin. Bedrooms had views across the gardens and the main road. Bedrooms were all bright and airy and furniture was of a good standard. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 18 Residents were seen relaxing after lunch in the small lounges either reading or watching television. There are small kitchens on each floor so that residents and/or their visitors can make a drink. There was enough housekeeping staff to keep the home clean and we noted that there were no unpleasant odours during the tour of the home. We saw that supplies of protective gloves and aprons were available to staff. There were also sanitising gels on the entry to each floor. All of these help to minimise the risks of infection. The dining rooms were bright and airy with a relaxed comfortable atmosphere Aids and adaptations were provided to assist in moving residents safely. These include manual hoists and assisted bathing facilities including a parker bath and a walk-in shower. There was evidence to show that staff had received manual handling training to enable them to use the equipment safely and safeguard residents. Corridors are wide and accessible to those residents who use wheelchairs. The home has a large chapel and has daily services that can be viewed on a special television channel and this meets the specialist cultural and religious needs of the residents. There is a pleasant seating area in the foyer and a bright and airy sun lounge residents were seen to use these areas. There are large well-maintained gardens with a number of seating areas where residents can sit out in the warm weather. Alexian Brothers Care Centre DS0000066876.V361485.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The number and skill mix of staff was sufficient to meet the needs of the residents accommodated and staff have access to a wide range of training. EVIDENCE: We looked at the recruitment records for three members of staff. These were generally well maintained. One staff file only had one reference on file and the last employer was not requested to supply reference. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been obtained for all staff to make sure that they are safe to work with the residents. It is strongly recommended that references be taken from the last employer or a reason recorded why this has not been done. Staff files contained photocopied documents, for example passports, utility bills and certificates but as stated in the last report there was no evidence that the original documents had been seen. It is recommended that that all photocopied documents are signed to indicate that the original had been seen. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 20 Staff are offered a good level of training in a number of topics, such as manual handling, Fire Safety, the Mental Capacity Act and Protection of Vulnerable Adults. They told us that each member of staff has a training record and they were in the process of producing a training matrix. This was not seen during this inspection. We saw that staff were very caring and spoke to residents in a polite and respectful manner. We saw that staff interacted well with residents and these relationships appeared very positive. Residents told us that staff were “ kind and caring”, “very helpful” and “quite friendly”. The new manager stated that she intended to provide staff supervision at regular intervals. There was evidence on staff files to show that staff were given a copy of their job description detailing their roles and responsibilities. Alexian Brothers Care Centre DS0000066876.V361485.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): Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Day to day management arrangements require further review to make sure that care staff receive the leadership and support they need and that systems are in place to protect residents. EVIDENCE: The post of registered manager has been vacant for approximately three months. The day-to-day management of the home has been overseen by the Responsible Individual. A new manager only took up post on the 7th April 2008 the day before this site visit. They managed the inspection well and have the necessary skills, qualifications and experience needed to manage a care home. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 22 They told us that they have a quality assurance questionnaire that is sent out on an annual basis to residents, relatives and staff. The feedback from this is used to improve the service. They told us there was an open door policy and residents and staff had access to senior staff at all times. Staff spoken to said that the management was always ready to listen to concerns and answer questions. Feedback from care staff was positive about the support they received from the home. Comments included “very supportive” and “the manager follows up the concerns of residents and staff”. They told us that staff supervision was not taking place but the new manager told us that she intended to start regular staff supervision. As stated in the last report, the home’s administrator has responsibility for residents’ monies. They had computerised records that were password protected and receipts were kept for any purchases made on the resident’s behalf. They told us that they had a meeting with residents and relatives the previous evening which new manager had attended. This was to introduce the new manager and to pass on information and to listen to people’s concerns and ideas. It was concerning to note that medication practices and care planning had not been improved and posed a potential risk to residents. The new manager demonstrated a good knowledge of person-centred care but this area still needs work to turn these ideas in to actual practice particularly in the area of medication and care planning. It is recommended that they look at who is leading the staff on each shift and making sure that this person is a role model in good person centred practice for others to follow. Health and Safety checks take place to make sure people are kept safe and records are kept of these. The new manager requested additional time to complete the Annual Quality Assurance Assessment required by the commission and this was agreed. Alexian Brothers Care Centre DS0000066876.V361485.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 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Alexian Brothers Care Centre DS0000066876.V361485.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 OP7 Regulation 13 (4) (c)12(1) (a) Requirement Timescale for action 15/05/08 2 OP7 17 (1) (a) Schedule 3 3 OP9 13(2) The care plan for each resident must contain detailed and individualised information about how their social, emotional and religious care needs are to be met and the plan kept under review. In order to evidence that the 15/05/08 identified needs of the residents are being met a record of the resident’s condition and any treatment given must be kept to reflect the care delivered. 1. Accurate records must be kept 09/04/08 in order to provide evidence that residents receive their medication as prescribed. The timescales of 16/10/07, 18/12/07 and 12/03/08 were not met and still apply. 2. Medication must be administered in exact accordance with the prescribers’ directions and there must be an adequate stock of medication for each resident, in order to protect residents’ health and safety The timescales of 16/10/07, 18/12/07 and 12/03/08 were not met and still apply. DS0000066876.V361485.R01.S.doc Version 5.2 Alexian Brothers Care Centre Page 25 4 OP36OP36 18 (2) 3. Medication must be accounted for at all times by means of an audit trail. When errors, discrepancies or concerns are identified, the action taken must be recorded The timescales of 16/10/07, 18/12/07 and 12/03/08 were not met and still apply. All care staff must receive 15/06/08 supervision with their line manager at least six times per year. This will help to make sure that good quality care is being delivered to people living at the home. The timescale of 12/03/08 not met. Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations To avoid confusion it is recommend that the care files are reviewed and filed in a secure and orderly fashion and all out of date information be removed. The home should look at ways to make the care plans more person centred and better reflect the individual’s life and preferences. The plan in place should direct the care to be person orientated and less task based. Care plans should give specific information about how the person likes the care and support to be delivered. Daily notes need to be reviewed to make sure that good quality useful information is being recorded. It is recommended that all photocopied documents are signed to indicate that the original had been seen. It is recommended that each resident has an individual interest bearing bank account. 3 4 5 OP7 OP29 OP35 Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI Alexian Brothers Care Centre DS0000066876.V361485.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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