Inspection on 27/04/06 for Alsager Court Care Centre

This inspection was carried out on 27th April 2006.

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

Alsager Court Care Centre 08/05/08

Alsager Court Care Centre 04/07/07

Alsager Court Care Centre 24/10/06

Alsager Court Care Centre 24/10/05

Alsager Court Care Centre 04/11/04

Alsager Court Care Centre 15/06/04

Alsager Court Care Centre 20/02/04

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

CARE HOMES FOR OLDER PEOPLE Alsager Court Care Centre Sandbach Road North Church Lawton Stoke On Trent Staffordshire ST7 3RG Lead Inspector Sue Dolley Key Unannounced Inspection 09:40 27th April and 5th May 2006 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 Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alsager Court Care Centre Address Sandbach Road North Church Lawton Stoke On Trent Staffordshire ST7 3RG 08453 455743 01270 883256 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) Mrs Sally Anne Manby Roberts Mr Jeremy Walsh Mrs Sylvia June Knox Care Home 27 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (27) of places Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 27 service users to include: * Up to 27 service users in the category of OP (old age not falling within any other category. * Up to 15 service users in the category of care with nursing (N) * Up to 7 service users in the category of DE (E) (dementia over 65 years of age) * The following bedrooms are excluded for the provision of care with nursing (N): 2,3,7,8,11,12,24,25,26 24th October 2005 Date of last inspection Brief Description of the Service: Alsager Court Care Centre is a 27- bedded care home for older people. Up to a maximum of 15 residents may have nursing needs and up to a maximum of 7 residents may be over 65 years of age and have dementia care needs. The home is situated off a busy main road in a residential area of Church Lawton, near Alsager. It provides ground floor accommodation and is set within two acres of landscaped gardens. There are 24 single rooms and 2 rooms, which could be shared to a maximum of 27 places. 16 of the rooms have en-suite facilities. The current owners took over the running of the home in September 2001. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 27th April 2006 and 5th May 2006 and in total took 9 hours to complete. A tour of the premises included all shared areas such as lounges, dining areas, shared bathrooms and toilets, the laundry and kitchen and a sample of residents’ bedrooms. Several staff members including an agency nurse, 3 residents and 3 visitors were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Some initial assessments had not been fully completed. Staff members must take greater care when administering and recording medication to ensure medication is given as frequently as prescribed and is clearly and accurately recorded. Up to date recruitment records and financial information must be accessible within the home for inspection purposes. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 6 Activities could be improved. Residents and relatives have expressed their disappointment in the low level of organised social activity available within the home. The staffing rotas could be better maintained to ensure they record the name of staff covering shifts. The person in charge and agency cover staff should be clearly recorded. 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. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 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 Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Prospective residents have their needs assessed prior to moving into the home to ensure their needs can be addressed and met. Intermediate care is not currently provided. EVIDENCE: The process of moving people into the home is well managed and although initial assessments and care documentation could be more fully completed it is evident that the majority of individual needs are met and residents quickly settle into their new environment. The pre- admission documentation and initial assessments for three recently admitted residents were checked and these residents were case tracked to ensure their needs had been identified, addressed and met. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 9 Resident A had a good and comprehensive care plan assessment and care plan in place. The reason for admission had been recorded. The pre admission assessment had taken place in hospital with a staff nurse present to confirm details. A good pen picture and medical history was provided. Since admission to Alsager Court Care Centre referrals had been made to the falls prevention co-ordinator and rehabilitation team. The care file was comprehensive with only a few omissions. Details of the residents’ religion had not been recorded. The residents day and night care plan had only been dated on the first page. Resident B had a care file containing a thorough assessment of need. Care plans relating to mobility and continence had been promptly reviewed with guidelines in place for staff to refer to regarding specialist continence aids to be used. A nurse assessor had been able to contribute to the assessment process by telephone. The care file did not contain information to be used in the event of a death. The assessment documentation for Resident C was comprehensive and was fully completed except information to be used in the event of a death had not been obtained and recorded. Each of the three care files checked contained a photograph of the person admitted, the date of admission and the name of their key worker. None of the three admission documents checked, had been signed by the person completing the forms. The registered manager explained that the staff members at headquarters were responsible for sending out forms to gather information to be used ‘in the event of a death’ and often these forms were not completed and returned. The registered provider stated that this information is requested as part of the admission process. When this information is obtained at Head Office it is forwarded to the home. The Registered Manager acknowledged that the nursing staff could ask this question as part of the initial information gathering process on the first day of moving in, however she stated that the next of kin details are always obtained and recorded. The three residents case tracked had a copy of their contract / on electronic file. The registered manager tried to access copies of the contracts on computer via ‘Scannet’, but the quality of information available to view was so poor these could not be read and checked and it could not be determined which rooms had been allocated upon admission. Copies of these contracts have since been received by the CSCI which record the room number. However, two of the residents had not had the contracts signed on their behalf. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 10 See Recommendation 1 Alsager Court Care Centre does not provide intermediate care. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9,10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including visits to this service. Although residents are well looked after in respect of their health and personal care needs, the recording and administration of medication needs improvement to ensure all residents receive their medication as prescribed. EVIDENCE: At the time of the site visit, seven residents with nursing care needs had moved in and were all allocated suitable rooms. Three plans of care checked detailed the action to be taken by staff to ensure all aspects of health and personal care were met. Risk assessments were in place regarding challenging behaviour, mobility, transferring, showering and bathing. The daily records of care provided full information; they stated all personal care tasks had been undertaken and indicated a high level of observation and continuity of care during each twenty- four- hour period of care. Care plans had been regularly evaluated and updated. Detailed records were kept of GP visits and community nursing visits and care had been adjusted accordingly. The standard of recording on some records regarding family liaison was poor. This issue had already been noticed by the registered manager and had been appropriately addressed prior to the site visit through staff supervision and monitoring the standard of recordings. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 12 The recording of the administration of medication was checked for the three people case tracked. One resident had a blank document on file relating to self- administration. Self -administration would not have been appropriate for this resident yet this was not indicated on the form. The medication administration records for April 2006 were checked for the three residents case tracked and were found to contain many unexplained gaps in recording and some medication was not given as prescribed. Information relating to the application of creams and ointments was not recorded on the medication administration records and when infrequently recorded on the daily care checklists the records did not indicate the type applied or time of application. Some laxative prescribed to be taken at set times were given ‘as and when’ required. The usage of inhalers was not recorded satisfactorily. Pain relief to be given every three days had been overdue by one day. Eight members of staff are currently trained to administer medication. There has been a failure to respond to medication requirements on three previous occasions, since 2004. The pharmacist inspector has been asked to visit. See Requirement 1. Service users spoken with confirmed that staff members respected their privacy and that all interactions are respectful and courteous. As previously mentioned in the report and at Recommendation 2, information to be used ‘in the event of a death’ should be recorded. Residents should be assured that at the time of their death, staff members would treat them and their family with care, sensitivity and respect. This cannot be achieved if information to be used ‘in the event of a death’ has not been obtained and recorded. The registered manager agreed that this question could be asked by nursing staff, although it may not always be appropriate to ask this on the first day when a resident moves in. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. There is very limited opportunity for residents to participate in activity to meet their needs, match their expectations and preferences. Residents receive a wholesome, appealing and balanced diet in pleasant surroundings. Personal preferences and choice are accommodated and alternative meals are provided upon request. EVIDENCE: Residents’ interests are recorded within the care files and residents meetings provide a forum for people to discuss their social and recreational needs. There was little opportunity for residents to participate in a planned programme of activities or to engage in local, social and community activities. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 14 The staffing rota was checked between 6th April 2006 and 5th May 2006. Staffing hours relating to the provision of activity totalled eight hours during this period. The registered provider has responded that 15 hours activity were provided per week but these were not clearly recorded. Since the site visit the rota has been amended to reflect these activity hours. An activities log is kept for each resident with occasional entries, such as listening to music and talking books, participating in a Grand national sweepstake, sing-a-longs, dominoes and discussion, throwing a ball, making cards for Easter, watching T.V and hair washing. Although a weekly programme of activities was displayed on the notice board in the reception hall there was little evidence of these or other activities undertaken on a regular basis. Minutes of residents meetings indicated that there was dissatisfaction with the low level of activity organised and available, although residents had previously been given assurance that requests would be acted upon. Some residents had suggested various activities and trips and had previously agreed to contribute to costs. Residents spoken with confirmed a lack of regular and suitable activity. 5 of 10 Commission for Social Care Inspection resident questionnaires completed during and since the site visit indicated a lack of activity and disappointment regarding this. The Statement of Purpose and Service User Guide states that a total of 15 care hours per week are provided for staff to organise basic social, recreational and cultural activities. Staff members, service users and visitors were unable to confirm that this amount of time was regularly available to plan, organise and provide activity. See Requirement 2. During the site visits several visitors to Alsager Court Care Centre, all received a warm welcome from staff and a good level of communication was observed for the benefit of residents. Residents were seen to enjoy their lunchtime meals and were given discreet help to eat in a relaxed, pleasant and social environment. Residents confirmed that meals were appetising and wholesome and that portions were provided according to preference and choice. Menus were available to view and alternative meals were supplied to residents who had made their preferences known to staff. The kitchen was well organised and clean and food stocks were plentiful. Some residents were able to eat in the privacy of their own rooms. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Concerns and complaints are recorded and records provide details of action taken and the outcome. Residents and their supporters are provided with contact information about accessing local advocacy services, which could help them protect their legal rights. EVIDENCE: The Statement of Purpose and Service User Guide contains a clear complaints policy and procedure with appropriate contact addresses to enable residents and their representatives to give details of their complaints and await a response. A copy of the Statement of Purpose and Service User Guide was not openly available in the home for reference purposes, but was later found stored in the office. The complaints records were checked. One complaint had been logged, recorded and appropriately resolved. A concern had been appropriately investigated and resolved. Alsager Court Care Centre has the contact information for local advocacy services, which could help residents to protect their legal rights. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 16 Twice yearly, staff members at Alsager Court receive mandatory training, about abuse and challenging behaviour. As a result staff are alert and aware to protect residents from abuse and can deal appropriately with challenging behaviour. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Residents live in a well maintained, and clean home which is decorated and furnished to a good standard providing a comfortable and homely environment for residents. EVIDENCE: Computer access to residents’ contracts was available but copies of documents were of poor quality and could not be read to determine and check the room numbers allocated to residents. The inspector was informed at a later date that the room numbers are recorded in the care plan. A tour of the premises was undertaken and included all shared areas. The premises were well presented, fresh, clean and welcoming. In discussion with residents and visitors positive comments were made regarding the constant and good standard of cleanliness throughout Alsager Court. The home is suitably equipped to aid mobility and the residents’ rooms are personalised to suit their needs although it is difficult for residents with wider wheelchairs to Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 18 safely negotiate some of the doorways within the home. The grounds are kept tidy, safe and attractive and are accessible to residents. To meet previous requirements the registered manager confirmed that all bedrooms now have two double electrical sockets in place. A diffuser had also been fitted to the fluorescent light in the hairdressing room. Advice was given to the registered manager at feedback to the site visit as some hair products were left on open shelving in the hairdressing room. There was evidence of regular water temperature checks to individual rooms and temperatures were within a safe range. Regular wheelchair maintenance checks had been undertaken to ensure safety. There was no written evidence of emergency lighting checks undertaken in October 2005 and February 2006. See Requirement 3 Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence at visits to this service. It is not always clear whether residents’ needs are met, by the numbers and skill mix of staff. EVIDENCE: The staffing rota is not sufficiently well maintained to evidence appropriate staffing levels, skill mix and person in charge arrangements when the registered manager is not on duty. The staffing rota between 6th April 2006 and 5th May 2006 was checked. On 2nd May it was unclear from the rota if a registered nurse was available to work on nights. There was no written evidence to confirm that there was, although the registered manager verbally confirmed there was from memory. The management arrangements for 19th and 21st April were unclear from the rota. The person in charge on the first day of the site visits was an agency nurse on her third visit to the home. Although there is printed information for new agency staff members and instructions regarding handovers, the agency nurse had only received a brief handover at her first visit to the home and had not had the fire procedure explained to her until her second visit. The induction process for agency nursing staff is not always adhered to, to ensure they have sufficient information to run the home effectively when they are left in charge. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 20 A number of negative comments were received about staffing levels. In 10 questionnaires completed during the site visits, by or on behalf of residents 3 reported that there was always staff available to them when needed, 3 reported that they usually had staff available, 3 reported that they sometimes had staff available and 1 was of the opinion that there wasn’t always sufficient numbers of staff on duty. Two residents said that although the staff members are helpful and kind they have difficulty in answering all calls, as there isn’t enough staff. One resident said that staff spoke of staff shortages and the demands of other residents to explain delays in answering calls. Cleaning staff members were described as pleasant people who never seemed to mind doing a little job. One resident was reluctant to ask for help believing that they were regarded as a nuisance for asking for a little help within their room. During the site visits there was one nurse and 2 carers on duty between 1pm and 7pm. At previous inspections there were one nurse and 3 carers on duty during the afternoons. During the whole of the rota period checked, only six two hour sessions of staff time had been identified for organising activities and some of these hours had not been used for this purpose as the activities co-ordinator was acting as relief cook. The registered provider has since stated that the activity time was provided but not recorded. See Requirement 4. As stated in the statement of purpose and service user guide dated March 2006, 7 of the 12 care assistants have achieved NVQ level 2 or above. The other staff are either Registered Nurses or housekeeping staff. Much of the recruitment information is stored on computer and the poor visual quality of the information stored made document checking very difficult. See Recommendation 3. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. The centre strives to run in the best interests of residents to promote and protect their health safety and welfare. More care is needed in the recording of person in charge arrangements. EVIDENCE: The registered manager is a qualified nurse and is competent and experienced in the delivery of care to older people. She has an open management style, is approachable and has recently achieved the registered managers award. The registered manager has twelve hours supernumerary management time each week. A positive and inclusive atmosphere has been encouraged within the home and both residents and staff feel supported. It would be good practice to ensure the person in charge arrangements during the registered manager`s absence are clearly identified on the staff rota. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 22 Agency staff should be recorded by name and agency on the staff rota to identify who is covering the shifts. These cover arrangements should be known to staff members. See Requirement 4. A quality monitoring process is in place with quality assurance questionnaires sent out to residents and relatives annually. Quality assurance questionnaires were posted out by the company headquarters on 28th April 2006 and responses had not been received at the time of the site visits or at the time of report writing. The registered provider has stated that “less formal systems are conducted by the manager and during monthly, unannounced visits to the home by a representative of Blanchworth Care. These provide opportunities for residents and/or relatives to share their views with staff about any aspect of the home including success of the home in meeting its aims, objectives and its statement of purpose”. Monthly monitoring visits are undertaken at Alsager Court, to monitor the practice and conduct within the home, and to provide guidance to management and staff during the visits. Monthly written reports are provided.. On the second site visit on 5th May 2006, a check of residents’ personal allowances was undertaken. The records were clearly and well maintained. The balances were checked. One balance contained an excess of 4p. The locality manager occasionally checks the personal allowances during monthly visits to the home. Advice was given to the registered manager at feedback to the site visit to ensure that residents’ financial balances are accurate at all times. Financial records and a business and financial plan for the establishment were not available for inspection within the home. It was therefore not possible to consider the accounting and financial procedures adopted to demonstrate current financial viability. The company headquarters are responsible for the accounting and financial procedures of the home. See Recommendation 4. A Business Plan has since been submitted to the CSCI by the registered provider. All accident records provided comprehensive information and there was evidence of safety procedures posted around the home for staff members to refer to. Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 2 3 X 3 3 Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 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 Requirement Arrangements must be made for the accurate recording, handling and safe administration of medicines received into the care home. (Similar requirements were made at the previous inspections on 4th and 9th of November 2004, 9th May 2005 and 24th October 2005). The registered person must consult residents about their social interests, and make arrangements to enable them to engage in local social and community activities. Ensure monthly emergency lighting checks are undertaken and recorded. The registered person must demonstrate, or provide evidence that appropriate person in charge arrangements are always recorded to provide continuity of care to residents and to ensure staff are appropriately supervised. Timescale for action 30/06/06 2 OP12 16 30/06/06 3 OP19 23 30/06/06 4 OP32 18 30/06/06 Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 25 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 OP3 OP11 Good Practice Recommendations Ensure pre admission documentation is fully completed and includes the name of the assessor, and the date the assessment was undertaken. Ensure that the information to be used ‘in the event of a death’ is obtained and recorded within the care file. Alsager Court Care Centre staff could sensitively obtain this information. Access to information and documents relating to staff recruitment and identity should be available for inspection purposes. (This recommendation remains outstanding from the previous inspections on 9th May 2005 and 25th October 2005). Ensure a financial plan for the establishment is available for inspection purposes. 3 OP29 4 OP34 Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alsager Court Care Centre DS0000006648.V289398.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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