Inspection on 19/09/07 for Alston House

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 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alston House 22/06/09

Alston House 22/06/09

Alston House 04/06/09

Alston House 05/05/09

Alston House 04/11/08

Alston House 03/06/08

Alston House 12/12/07

Alston House 19/04/06

Alston House 12/12/05

Alston House 22/08/05

Alston House 22/11/04

Alston House 20/07/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Alston House 380 Aylestone Road Leicester Leicestershire LE2 8BL Lead Inspector Diane Butler Key Unannounced Inspection 19th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alston House DS0000006408.V341567.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. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alston House Address 380 Aylestone Road Leicester Leicestershire LE2 8BL 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) 0116 291 5601 0116 291 5611 Mrs Margaret Madden Manager post vacant Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (19), Old age, not falling within any other category (19), Sensory Impairment over 65 years of age (2) Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No person falling within categories OP, MD(E) or DE(E) may be admitted to the home when 19 persons of categories/combined categories OP, MD(E), DE(E) are already accommodated within the home. Service user numbers. No person falling within category SI(E) may be admitted to the home when 2 persons of categories/combined categories SI(E) are already accommodated within the home. The maximum number of persons to be accommodated at Alston House is 19. 19th April 2006 2. 3. Date of last inspection Brief Description of the Service: Alston House is a care home for older persons, providing accommodation and personal care for up to nineteen residents some of whom have mental health needs, dementia and/or a sensory impairment. The home is situated on the Aylestone Road in Leicester approximately 15 minutes away from the city centre. There are shops within five minutes walking distance from the home and there is a small park nearby. Accommodation is on two floors with the upper floor accessed by lift or stairs. There are three lounges, two dining room areas and a conservatory on the ground floor. The home offers both single and shared bedrooms some of which come with ensuite facilities. A large parking area is to the front of the home and there is a well-maintained garden to the rear of the home. Current charges range from £330.00 per week to £440.00 per week. Additional charges are in place for hairdressing, chiropody treatment and transport to appointments. Details of all charges can be found in the homes Statement of Purpose document, (a document which provides relevant information about the home) which is given to all prospective and current residents. A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the acting manager. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a six and a half hour period on Wednesday 19th September 2007. The acting manager was on duty at the time of the inspection. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, speaking with them when possible and discussion with staff on duty at the time of the visit. Where communication was difficult, observation was used to evidence whether care needs were being met. A further two residents, two relatives and a community nurse were spoken with during the site visit. Further planning for the site visit included checking the service history and last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. Questionnaires were also sent to a selection of residents and their relatives to gain their views of Alston House. Comments received include: “I love games”. “I spend a lot of time in my room, it is good to know that the staff check on me and that if I require them they are there”. “Always things to do but I am a creature of habit and therefore choose not to participate. I prefer solitude” “I get on very well with the manager [acting] and deputy manager, I can always speak to them anytime”. “They try to make it as homely as possible and the staff are always friendly”. What the service does well: Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 6 There is a relaxed and friendly atmosphere within the home and staff go about their daily work in an unhurried and professional manner. Comprehensive care plans and risk assessments are in place and care workers are well aware of the current care and support needs of the residents. Residents are offered choices on a daily basis, including what time to get up, where to eat their meals and whether to join in activities provided. The acting manager is both supportive and approachable and families and friends are encouraged to be involved in the life of the home. What has improved since the last inspection? What they could do better: Ensure that recruitment procedures are adhered to. Residents need to be protected by the recruitment procedures that are in place. Ensure that the recording and storage of medicines is in line with the medication policy. Ensure that money and valuables kept on behalf of the residents is appropriately stored and documented. Residents need to be assured that their money and valuables are safe at all times. Ensure that records relating to the residents are up to date, accurate and kept secure. Ensure that an advocacy service is available for residents who need assistance with their personal finances, this will protect both the resident and the staff working in the home. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 7 Ensure that the home is kept well maintained. Areas identified as in need of attention including carpets and decoration should be addressed as soon as possible. Ensure that activities provided in the home are recorded, this will enable the care workers to provide a more varied programme and reduce the possibility of duplication of activities. Ensure that a thorough needs assessment is completed for all new residents to make sure all care needs are identified. Ensure that quality assurance questionnaires are used to gather the views of the residents and/or their relatives and make the results of these available to interested parties. This would show residents and relatives that their views on the service provided are valued and taken seriously. Ensure that care workers have regular moving and handling updates. This will enable the care workers to continue to move and handle residents safely. 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. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are assessed, however, lack of written information could possibly lead to some needs not being identified and therefore not being met. EVIDENCE: A statement of purpose document is in place. The acting manager stated that this document, which includes details of the terms and conditions of occupancy, is given to all prospective residents. This was confirmed on speaking with two relatives visiting the home at the time of the visit who both confirmed that they had received this information. The acting manager stated that all prospective residents are visited either in their own home or in hospital so that an assessment of need can be carried out and a copy of the assessment from their social worker is also obtained. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 10 All prospective residents and/or their relatives are also invited to look around the home prior to moving in, in order for them to see what the home has to offer. On checking the files belonging to three residents it was noted that two residents funded by social services included a copy of the needs assessment completed by their social worker and one included a needs assessment completed by the home. The inspector was informed that the second resident had been assessed by the deputy manager but no paperwork had been completed. On checking the third file belonging to a resident who is self funding, it was noted that a brief report had been received from the previous home where the resident lived and a basic assessment had been completed by the acting manager. Whilst checking the paperwork belonging to the resident who is self funding it was noted that their was no contract in place. The acting manager explained that the resident refuses to sign a contract and issues around her finances were currently a concern. It was strongly recommended that the acting manager contact an advocacy service to support the resident with this issue. On speaking to two relatives the inspector was informed that they had been able to look around the home before their relative moved in. One relative explained “We came and had a look around before mum came in” At the time of the visit Alston House was not providing intermediate care. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are currently looked after well in respect of their health and personal care needs. EVIDENCE: On checking the files belonging to three residents it was noted that all included a comprehensive plan of care. The acting manager stated that the care plans were normally reviewed on a monthly basis though this had slipped slightly due to staff sickness. On checking the files it was noted that all three care plans had been reviewed though not on a monthly basis. All three care plans included details as to why the resident needed the help and support and what actions the care workers needed to take to meet their needs. Individual likes and dislikes were also highlighted, including what time the resident preferred to get up and go to bed. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 12 On checking the care plan belonging to a resident who at times displays challenging behaviour it was noted that this was fully covered within the care plan and risk assessment documentation. The care plan included information on behaviours that the resident tends to display before they become aggressive and gives examples of actions the care workers can take to try to diffuse a situation. All the care workers spoken with confirmed that they read the care plans on a regular basis to ensure that they were up to date with the residents needs. Risk assessments were included in the files checked. These again were thorough in content and covered all the risks identified within the care plan documentation. On checking the daily records it was evident that the residents have access to appropriate healthcare professionals including the local GP and the community nurse who was at the home during the visit. Medication records were checked. Those checked showed that the medication had been signed into the home appropriately and signed for when given to the residents. It was noted that for two residents who were assisted to take temazepam this medication hadn’t been recorded appropriately in the controlled drug file, which is normal procedure, though it was recorded in the medication charts. The acting manager stated that this would be addressed straight the way. On checking the eye drops stored in the medication fridge it was noted that not all had been dated when opened to ensure that they are only used for 28 days and two bottles of the same eye drop were opened at the same time for one resident. This was resolved at the time by the senior carer destroying the old bottle of eye drops. Residents and relatives spoken with during the visit stated that they were well cared for and there current care needs were being met. Comments received included: “She always looks well cared for”. “I am very satisfied with the care my dad is receiving”. “There not bad, they look after me nicely” Interaction between residents and staff was very positive on the day of the visit with staff members speaking to residents and visitors in a respectful and friendly manner. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visiting is strongly encouraged to enable residents to maintain contact with family and friends. EVIDENCE: Choices are offered on a daily basis including whether to stay in bed or to get up, what to wear, what and when to eat and whether or not to join in the activities provided. Activities are provided twice a day, the acting manager explained that there is no formal activities programme but the care workers on duty provide a number of games and one to one sessions whilst on duty. During the visit a number of residents were seen joining in a game of skittles and a resident and a member of staff were going through the daily paper. Although these activities are not currently recorded, care workers spoken with confirmed that these sessions are provided on a daily basis and a relative confirmed that activities do take place. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 14 Family and friends are encouraged to visit. Relatives spoken with during the inspection confirmed that they were always made welcome and were able to visit at any time. Comments received included: “The staff are very friendly and usually offer me a drink”. “I am always made welcome”. “The atmosphere is much better since the acting manager took over and I am always welcomed”. Residents spoken with stated that the food was good and nutrional assessments are included in their care plan documentation. On checking the menu it was noted that a nutritious and balanced meal is provided every day and the meal seen during the visit was well presented, hot and appealing in appearance. It was noted that the menu did not record an alternative meal if someone didn’t like what was on offer. The acting manager stated that an alternative is always available and it was evident during the visit that those who didn’t like the main meal that day had been provided with an alternative. One resident explained “I don’t like fish so I had sausage today”. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements for the receiving and responding to complaints are in place. EVIDENCE: A complaints procedure is in place. A copy of this can be found on the notice board situated in the hallway near the front door and details are also included in the Statement of Purpose, which is given to all residents (or their relatives) living at the home. Two concerns have been raised with the owner of Alston House since the last inspection in April last year. These concerns, which regarded issues around the moving and handling of residents, safeguarding procedures within the home and an infestation of insects, were investigated and actions were taken to address the concerns raised. Training in abuse awareness has been provided and staff members spoken with during this visit were aware of the actions to take should they suspect any form of abuse. The acting manager stated that she was aware of the procedure to follow should any form of abuse be suspected and a copy of the safeguarding adults protocol is available for reference. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 16 Concerns around the reporting of incidents to both social services and the Commission for Social Care Inspection have been raised on more than one occasion since the last inspection and the owner and acting manager are now aware of their responsibility for reporting any incident or event that effects the well being of the residents in their care to the appropriate agencies. Alston House DS0000006408.V341567.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): 19,20,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable place to live though, attention to outstanding decoration and replacement of certain flooring would further improve the environment. EVIDENCE: A number of changes have been made to the environment since the last inspection. A new quiet lounge has been created at the front of the home and the flooring has been replaced in the small lounge and conservatory at the rear of the home. A shower has been installed in the bathroom on the ground floor and an assisted bath is available on the first floor. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 18 The acting manager explained that a number of rooms have had sinks and vanity units installed and new furniture has been provided in some of the communal areas. Furnishings in the lounge areas, dining areas and conservatory are domestic in character and in good condition. It was noted that a number of the doors to residents’ rooms and in corridors were badly scratched. Two residents rooms were seen during the visit and were found to include some personal belongings. A discussion took place with the acting manager with regard to the stained carpet in the main lounge. The inspector was informed that regular cleaning had not restored the carpet to a reasonable state and it was the owner’s intention to replace it in the near future. There is a garden to the rear of the home that residents can access and benches are available for residents and visitors to use. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although staff are trained to carry out their roles effectively current recruitment practices put residents at risk. EVIDENCE: There were sufficient numbers of staff on duty on the day of the visit to meet the current needs of the residents. Relatives spoken with felt that on the whole there were enough staff on duty to meet their relatives needs and the care workers spoken with felt that there were normally enough staff on each shift to care properly for the residents. Four staff files were checked, two of which were employed prior to the acting manager being in post and two who had been employed by the acting manager. It was noted that although all had CRB checks in place the two care workers employed prior to the acting manager taking up post in January this year had not had new CRB checks requested. A statement in the staff application form states ‘Alston House will apply to the Criminal Record Bureau for a disclosure. Existing disclosures are not acceptable and will need to be repeated’. This was not the case, as a care worker who started work on 21st November 2006 had a CRB clearance on file dated 7th December 2005. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 20 It was also noted that for a care worker who commenced work on 2nd March 2007 the POVA 1st check was dated 30th April 2007 and CRB check was dated 8th May 2007. On speaking to a domestic worker working at the home the inspector was informed that it was their first day working at the home, on requesting their file to check that the relevant checks were in place it was evident that no checks what so ever had been carried out. An immediate requirement was issued at the time requiring the acting manager to address this issue, which she did by asking the worker to stop work and leave the home until the necessary checks could be sought. An induction programme is in place and all care workers spoken with confirmed that they had received induction training. A number of training sessions have been provided since the last inspection including: Abuse awareness training Palliative care training MRSA awareness Challenging behaviour and managing aggressive behaviour Diversity and Equality training. Eight members of staff have completed their National Vocational Qualification level 2 and a further three are in the process of completing this qualification. Alston House DS0000006408.V341567.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 poor. This judgement has been made using available evidence including a visit to this service. Although residents benefit from the overall ethos of the home, which the acting manager provides, they are not fully protected by the homes record keeping, policies or procedures. EVIDENCE: At the time of the visit the home was without a registered manager. The acting manager has twenty years experience in care and is currently completing her NVQ level 4. Relatives and visitors at the home at the time of the visit stated that the acting manager was approachable and would have no hesitation to talk with her should they need to. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 22 Comments received included: “Things have improved since xxx [the acting manager] took over”. “The manager [acting] treats the residents very much as individuals, I have nothing but praise for her”. Care workers spoken with felt supported by the acting manager and all stated that there was always someone available to talk to should they need to. The inspector was informed that staff meetings take place and this was confirmed on speaking with three care workers. On checking four staff files it was noted that supervision sessions had been provided in May and August this year. On speaking with the acting manager it was evident that formal quality assurance questionnaires are not currently distributed however it was noted that she had close links with residents, relatives, staff and visiting professionals. She explained that she meets with all the residents on a day to day basis and staff sit together at the end of each shift to discuss any issues that have arisen. On checking money held on behalf of two residents it was noted that this was held in separate envelopes but was not formally recorded any where. It was also noted that there were a number of items held in the safe such as wedding rings and chains that had no names on them and the acting manager did not know whom any of the items belonged to. On checking the daily records it was noted that these were up to date and an entry made after each shift. On checking the accident records it was noted that not all corresponded with the daily records i.e. one resident had had an accident with their finger, an accident form was completed but this was not recorded in the daily records. For a second resident it was noted that an accident form had been completed on the 22nd May 2007, which stated that the resident had suffered a fall at 5.15am. On checking the daily records this was not mentioned. On checking the handover book, it stated that the resident had actually suffered two falls that day one at 1.00am and one at 5.15am only one had been recorded in the accident book and neither had been recorded in the daily records. The acting manager explained that she had spoken with the care staff about recording all information in the daily records and would again remind them all of the importance of this. Daily records are currently kept on top of the cabinet in the dining area. It is strongly recommended that these be kept in the office to ensure confidentiality. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 23 Health and Safety training and moving and handling training have been provided since the last inspection in April last year. On speaking to a community nurse who was at the home on the day of the visit the inspector was informed that the moving and handling of residents had improved but it still needed some work, this was discussed with the acting manager who agreed with this statement and agreed that the staff would need regular updates to ensure that they continued to move and handle the residents appropriately. Training in Infection control and First aid has also been provided for a number of the staff working at the home. Alston House DS0000006408.V341567.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 2 X 1 3 1 3 Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 17(1)(a) Requirement The registered person shall maintain in respect of each service user a record which includes the information, documents and other records specified in Schedule 3 relating to the service user. The registered person must ensure that all medicines are appropriately signed for and kept in line with the homes medication policy. Staff must adhere to the homes procedures for the recording and storage of medicines. 2 OP29 19(1)(b)(i The registered person shall not employ a person to work at the care home unless-he has obtained in respect of that person the information and documents specified in Schedule 2. 1.The registered person must obtain an up to date CRB on recruitment of all care workers. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 26 Timescale for action 30/09/07 30/09/07 2. The registered person must ensure that appropriate references are obtained. Residents need to be protected by the recruitment procedures that are in place. 3 OP35 17(2) The registered person shall maintain in the care home the records specified in Schedule 4. A record of all money or other valuables deposited by a service user for safekeeping or received on a service users behalf must be kept. Resident’s money and valuables must be protected at all times. 4 OP37 17(1)(a) The registered person shall maintain in respect of each service user a record which includes the information, documents and other records specified in Schedule 3 relating to the service user. The registered person must ensure all records are up to date, accurate and kept secure. Resident’s records need to be protected and kept in line with the Data Protection Act 1998. 30/09/07 30/09/07 Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP2 OP3 OP12 OP19 OP33 OP38 Good Practice Recommendations The registered provider should source an advocate to assist the resident identified during the visit with their contract and finances. The registered provider should ensure that a thorough needs assessment is completed before a resident moves into the home to ensure all care needs are identified. The registered provider should ensure that the activities provided by the care workers are recorded. The registered provider should deal with the areas identified as in need of attention, including flooring and decoration as soon as possible. The registered provider should recommence the use of quality assurance questionnaires to gather the views of the residents and/or their relatives.. The registered provider should ensure that regular updates on moving and handling is provided to all staff. Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Alston House DS0000006408.V341567.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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