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Inspection on 19/09/07 for Alicia Nursing Home

Also see our care home review for Alicia Nursing Home for more information

This inspection was carried out on 19th September 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Alicia provides care and support to people with a range of needs within a clean and well decorated environment. The home is divided for operational purposes, so although the home is registered for 61 adults, care is provided to smaller groups but smaller groups of staff. The staff team appear happy, which has resulted in many of them working for the company for a number of yearsPeople living at the home have access to a day centre, which is opened every day and can be opened in the evening. A number of trips, activities and excursions are also provided by the home. The manager is well respected by the staff ,and leads by example wherever possible. She is committed to providing a good quality of care and regularly audits what staff have done and are doing.

What has improved since the last inspection?

Since the last inspection the manager and staff had worked hard to improve the care plans and make sure they gave detailed information, which resulted in the residents receiving a consistent standard of care. In addition to the work on the care plans any personal and social activities had been risk assessed and the risk assessments and any associated documentation had been clearly written and were being used to ensure safe care was provided.

What the care home could do better:

There were no requirements made at the end of this inspection and only two recommendations. One that the care plans included a copy of the service users photograph as a means of identification. The manager had taken the photographs but had not put them onto the individual files and two that when making any future environmental changes the needs of those residents with dementia should be considered.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Alicia Nursing Home 109-115 Marsh Road Luton Bedfordshire LU3 2QG Lead Inspector Sally Snelson Unannounced Inspection 18th September 2007 09:15 X10029.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 Alicia Nursing Home DS0000017661.V351779.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 and Care Homes for Adults 18 – 65*. 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. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alicia Nursing Home Address 109-115 Marsh Road Luton Bedfordshire LU3 2QG 01582 560500 01582 561574 karen@apexcare.co.uk 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) Apex Care Homes Limited Mary Mukangwa Tengenesha Care Home 61 Category(ies) of Dementia (16), Dementia - over 65 years of age registration, with number (16), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24), Physical disability (21), Physical disability over 65 years of age (21) Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No service user under the age of 50 may be accommodated at the home unless an additional condition has been made. Service users admitted from 25.02.06 in the category of MD or MD(E) will be accommodated in the Wingfield Unit. Service users admitted from 25.02.06 in the category of DE or DE(E) will be accommodated in Alicia on the Yellow floor (Middle Floor). Service users admitted from 25.02.06 in the category of PD or PD(E) will be accommodated in Alicia on the Red and Green floors (Ground and top floor). The three service users identified in the application letter dated 21.02.06 in the category of LD may be accommodated at the home until such time as a change of placement is required. The one service user identified in the application letter dated 21.02.06 in the category of LD(E) may be accommodated at the home until such time as a change of placement is required. The one service user under the age of 50 years identified in the application letter dated 21.02.06 in the category of PD may be accommodated at the home. The one service under the age of 50years identified in the application letter dated 21.02.06 in the category of DE may be accommodated at the home. 18th May 2006 6. 7. 8. Date of last inspection Brief Description of the Service: Alicia Nursing home is situated on the Marsh Road in Luton close to a variety of local amenities such as shops, places of worship and public houses. The home provides accommodation over three floors within one building and over two floors in another building known as Wingfield unit. For operational purposes each floor provides its own style of care for a particular group of service users. Attached to the home is a day centre that is staffed to provide activities for any of the residents who wish to attend Monday to Friday. The care staff can open this centre at weekends or in the evenings. The home has a small-enclosed garden with parking space for staff and visitors. The home is close to the M1 and the A6 and is on a bus route. Leagrave railway station is easily accessible. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 5 The fees for this home vary from £561.00 per week, to £974.00 per week, depending on the funding source. If a higher staff ratio is required due to the assessed needs of the resident, fee levels will be above this figure based on the additional staffing costs. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA), and from the 18 service users who completed questionnaires has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. This report is written on a mixed category template as the home is registered to provide care to service users over the age of 50 years. At the time of the inspection more people living at Alicia were over 65 years of age than under. The inspection of Alicia was a key inspection, was unannounced and took place from 09.15am on 18th September 2007. The registered manager, Mary Tengenesha, was present throughout. Feedback was given at the end of the inspection to the manager and the deputy manager. During the inspection the care of four people who used the service was case tracked. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, staff and visitors were spoken to and their opinions sought. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: Alicia provides care and support to people with a range of needs within a clean and well decorated environment. The home is divided for operational purposes, so although the home is registered for 61 adults, care is provided to smaller groups but smaller groups of staff. The staff team appear happy, which has resulted in many of them working for the company for a number of years. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 7 People living at the home have access to a day centre, which is opened every day and can be opened in the evening. A number of trips, activities and excursions are also provided by the home. The manager is well respected by the staff ,and leads by example wherever possible. She is committed to providing a good quality of care and regularly audits what staff have done and are doing. 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. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1,2,3,4,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There was clear information available to service users prior to them moving into Alicia, which meant that they, or their families, were able to make an informed choice about the home. EVIDENCE: Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 10 The Statement of Purpose included all the information required by the National Minimum Standard. The Statement of Purpose and a Service Users Guide was seen in each of the resident files. These documents were clearly written. There was a contract on all files; there was a distinction between those provided to residents who were privately funded and those funded by their local authority. In all the files sampled we noted that the registered manager had assessed prospective residents, prior to admission. The assessments were thorough and the information gained and any other information, from placing social workers or those previously involved in the residents care, had been used to formulate care plans. At the time of the inspection the home had a waiting list, particularly for dementia beds. It was clear that the staff team had the necessary experience and qualifications to meet the assessed needs of the residents. See staffing section of this report. The home did not provide intermediate care. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of care planning and risk assessment was such that care staff could provide a suitable level of care and support to residents. Therefore those people living at Alicia could be sure that their needs would be met. EVIDENCE: Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 12 Work had been ongoing to improve care planning, and risk assessments. In all the files sampled it was clear what care the resident needed and how they liked the care to be given. It was also apparent that residents, and in some cases family members, had been involved in the writing and reviewing of the care plans, particularly life histories and personal likes and dislikes. Care plans had been written in a person centred holistic way. Care plans had been reviewed at least monthly and where necessary changes had been made. The care plans were stored neatly in individual files and each plan lead into the appropriate risk assessment and any other further documentation. For example a care plan on nutrition detailed how the resident liked to have their meals and their personal likes and dislikes, included a nutritional assessment tool and regular weight checks, if that was what was required. The requirements made about care planning and risk assessment at the last inspection had been fully met to a high standard. Every six months graphs of assessments were produced to indicate how needs had changed. During the inspection we noted that residents looked comfortable and well looked after. A number spoke to us and confirmed they were indeed happy and well cared for. Staff were kind and sensitive when dealing with residents, and were mindful of the need for privacy when giving personal care. It was apparent that staff addressed residents in different ways according to their preferences for example we heard some being called by their first name and others by their title and surname. Staff appropriately used a variety of moving and handling equipment. Some residents also had specialist equipment such as pressure relieving mattresses and cushions and mobility aids. The home had a good relationship with local GP’s and hospital consultants, in addition to other health care professionals such as, therapists, specialist nurses, dieticians, dentist, and optician. As part of the satisfaction questionnaires received prior to the inspection a relative had enquired why it was necessary to pay for physiotherapy. The manager confirmed that any resident who has been professionally assessed as benefiting from physiotherapy to improve their condition would receive this service. However if it had not been deemed as necessary a private physiotherapist was available in the home at a cost to the resident. As stated at the last inspection, ‘Resident care records contained medication profile sheets; these listed all medications past and present that the resident had been prescribed. Entries on these documents matched the homes medication administration records and the medication stocks for the residents.’ Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 13 The supplying pharmacy did regular individual audits on all residents’ medication. Most of the residents had some information about their wishes at the time of death. Where the staff had not been able to get any information there was a note to speak to relatives at the time. Where specialist cultural or religious needs were to be observed these were recorded. All of the files had details about when and who to contact in the case of sudden illness or death. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offered residents a flexible lifestyle ensuring they could live as close to they way they wished as possible. EVIDENCE: Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 15 We noted that residents could get up and go to bed when they wished and those that were assessed as able could leave the home. A day centre in the home was run between Monday and Friday by dedicated staff specifically employed to meet the social needs of the residents. At the beginning of the inspection some of the residents were waiting for the centre to open. One resident said ‘I love going to the day centre and meeting everyone’. It was open to any residents on any day. However on specific days, for each area of the home, staff encouraged those residents that were reluctant to participate to join in. In addition to the activities provided by the day centre outside entertainment and trips out were also arranged. Since the introduction of the more detailed care plans residents and/or their families had been asked more about their previous lives and interests and this information had been used to plan activities. Residents, staff and families were encouraged to be part of the Friends of Alicia group that supported trips out and social events. The weekend prior to the inspection there had been a fete at the home, which was well supported and attended. Service users also spoke of a trip to the London Eye and Willen Lake. One resident stated that he was supported every Friday to attend prayers at the Mosque and was very grateful for this. He was also being helped to arrange a trip to Mecca. One resident explained his involvement in staff recruiting and showed us the form he had to complete when involved. It was apparent that the home would involve advocates for those residents that needed it. At lunchtime a choice was offered, and people had chosen their meal in advance. Blended meals were presented attractively, so that the component parts could be recognised easily. Staff were very attentive to the needs of some residents to have help with eating, and they assisted in a caring, unrushed, and careful manner. The staff team had a range of backgrounds, and the manager reported that they had been happy to help by providing and preparing specialist meals for residents who enjoyed English food but would also enjoy the food from their country of origin on occasions. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff take any complaints very seriously, and they listen to what people say. Staff had learnt about how residents can be at risk of harm. Therefore people living at the home can be sure that they will be listened to and protected from harm. EVIDENCE: The home had a clear complaints procedure and only one of the 18 returned questionnaire stated that they did not know how to make a complaint. The complaints log included all complaints whether they were considered serious or trivial. As a result there had been six complaints since the last inspection and one had been upheld. There complaints log also included an audit trial as to how the complaint had been dealt with from the start to its conclusion. Visitors and residents were also encouraged to use the suggestion box and to talk frankly at resident and stakeholder meetings. The home had received a number of compliments over the past year including a letter of Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 17 thanks from a GP for the homes support to a resident while following a weight loss plan. The home had a whistle blowing policy that had been used to the benefit of the residents receiving care. Staff spoken to were able to say what they would do in certain circumstances relating to possible abuse, and if they should receive a complaint. All staff had taken the opportunity to attend mental capacity and safeguarding training to ensure that all residents were protected from any forms of abuse. We were aware that the home had a good relationship with the Local Authorities safeguarding co-ordinator and could seek advice. There had been one incident of concern earlier in the year when a service user had wandered off into water during a day trip. A strategy meeting had confirmed that more could have been done to prevent this but that the resident had come to no harm, extra dry clothes were available, and the member of staff had been disciplined for failing to thoroughly risk assess the situation accurately in the managers absence, it was not considered a safeguarding incident. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,20,21,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was kept clean and tidy and in a good state of repair by a dedicated ancillary staff team. Therefore people at the home could be sure that they lived in a comfortable homely safe place. EVIDENCE: Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 19 The home was across two adjacent sites, one site covered three floors and the other two floors. The two sites shared a secure garden area and parking facility. All of the areas of the home were clean and tidy; some were in a better decorative state of repair than others. The manager was aware of the need to possibly make some environmental changes to the dementia unit and as a result was planning to visit other local dementia units for ideas. All of the bedrooms were fit for purpose and residents were encouraged to furnish them with personal processions from home if they wished. The home had been adapted with aids and adaptations, for example walk in showers, ramps to the garden and appropriate hand rails. There was an on-going plan for improvement and redecoration throughout the building as a routine and as necessary. All of the rooms, when vacated by a resident, were redecorated and where possible residents could choose the décor. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s commitment to staff training meant that a staff team with the necessary training, experience and qualifications to do so provided care to the residents. EVIDENCE: For operational purposes the staff were divided into teams to cover each of the floors of the building, known as green, yellow and red and the Wingfield unit. The staff team on each floor was determined by the needs of the residents and although staff and residents commented that more staff would be good, all Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 21 said there were sufficient to meet needs. Each of the unit always had at least a qualified nurse and a senior carer on duty with care staff at any time. At the time of the inspection there were three vacancies, but staff were covering these by doing some extra shifts. The manager had had a large response to a recruitment advertisement and was confident that these posts would soon be filled. As with other care homes in the area the ethnicity of the staff team did not relate to the ethnicity of the residents living at the home. During the night of the inspection a resident had unexpectedly been moved to hospital. A member of staff had accompanied them and stayed there and then been replaced in the morning by another member of staff. The home should be commended for the commitment to ensuring residents continuing care needs were met. Staff were supported to obtain NVQ’s. In addition to senior carers being equivalent to NVQ level 2 or above by virtue of being qualified nurses in their country of origin, 12 carers had NVQ level 2, and a further four had enrolled on the course. The home was able to recognise additional training by enhanced pay to staff completing this training. All new carers received structured induction training over a period of twelve weeks (probationary period). In addition to the induction training staff were expected to undertake mandatory training, including safeguarding, infection control and moving and handling. Staff confirmed that additional specific training was available such as diabetic training from the diabetic community nurse as and when required and they could always request a specific training. External training was often consolidated internally and competence questionnaires used as support. A sample of staff files demonstrated that proper recruitment procedures were in place, and that correct checks were made before anyone was allowed to work at the home. As already stated, residents were encouraged to be part of staff recruitment. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,32,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run in an efficient way and the views of residents were considered regularly ensuring that the home was run in their best interest. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Home Manager had many years experience, which was directly relevant to her role as manager of the home. In addition to being a Registered General Nurse, a Registered Mental Health Nurse and holding the Registered Managers Award she had a mentoring and support qualification at degree level and had recently completed a postgraduate qualification in clinical leadership. The manager often worked on the floor at weekends to be alongside the residents and staff. Staff and residents confirmed that the manager was available to them at all times and would always offer them advice and support. It was apparent that she led by example. Residents finances were checked, balances were correct and money held on behalf of residents was available at anytime. Auditing of the finance was carried out as part of the Regulation 26 visit by one or more of the management team. Residents were also supported to hold bank accounts as they wished and bankcards could, if the resident wished be held by the home or in a locked drawer in their room. The home had been accredited as an Investor in people since 1997 and looked at innovative ways in which to seek stakeholder comments; such as ‘Your say’ questionnaires, regular resident and staff meetings and a suggestion box. The Annual Quality Assurance Assessment completed by the manager accurately reflected the home and was of a high standard. By training senior staff as supervisors the supervision programme was on track to ensure that all staff received at least six supervisions during the year. The homes Health and Safety policy was noted to contain all required information. Staff confirmed that they had undertaken fire, manual handling, food hygiene and first aid training. Risk assessments had been undertaken and were seen on the service users care files that were tracked on this inspection. All major equipment was serviced regularly and the home maintained documentation to support this and when safety checks such as recording water temperatures had been undertaken. In June 2007 the home was awarded 4 stars from Luton Borough Councils Environmental Health Department Routine safety checks had been maintained and the last visit by the fire service on 3rd July 2007 had been satisfactory. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 3 4 3 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 X 23 X 24 3 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 4 33 3 34 X 35 3 36 3 37 X 38 3 Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 25 NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations All care files should include a photograph of the resident to aid identification, Consideration should be given to making the environment as suitable as possible for those people with dementia. 2 OP19 Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. Alicia Nursing Home DS0000017661.V351779.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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