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Inspection on 20/12/06 for Princess Alexandra House

Also see our care home review for Princess Alexandra House for more information

This inspection was carried out on 20th December 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.

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

Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are respected.Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home. Residents are provided with regular fulfilling activities. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Residents and staff benefit from supportive and approachable management within the home. Procedures in place for the handling of personal allowances ensure residents` finances are safeguarded.

What has improved since the last inspection?

Five out of the six requirements have been met since the last inspection. The Registered Manager confirmed that the Service User`s Guide has been amended. Other requirements and recommendations made that have been met are; there is a suitable book in place for the recording of controlled drugs, all personal belongings have been removed from communal areas and fridge and freezer temperatures are now being recorded on a daily basis. An individual`s wishes following death are discussed at their six monthly review and the home is working towards ensuring 50% of staff obtain National Vocation Qualification (NVQ) level 2. The Registered Manager has obtained the recommended qualifications.

What the care home could do better:

Thorough pre admission assessments need to be undertaken to evidence that the home can meet all of the assessed needs for prospective residents. There are plans to change the care plan format. Care plans must cover all aspects of health, personal and social care needs and provide staff with clear and up to date information on how to meet these assessed needs. Urgent action is required to ensure that clear and accurate records are maintained for the administration of medicines, ensuring residents medical needs are met and staff are safeguarded. It is recommended as good practice that handwritten prescriptions on Medication Administration Records (MAR) charts be checked and double signed by two staff who have undertaken medication training and that any hand written amendments on MAR charts are signed. It remains an outstanding requirement that robust recruitment procedures be followed to ensure that residents remain safeguarded. It is required that the home removes all door wedges and consult with the fire authority regarding suitable measures to take in regards of `propping open` fire doors. Other minor shortfalls that have not been reflected as recommendations have been highlighted throughout the inspection report.

CARE HOMES FOR OLDER PEOPLE Princess Alexandra House 34 Preston Park Avenue Brighton East Sussex BN1 6HG Lead Inspector Jennie Williams Unannounced Inspection 20th December 2006 10:30 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 Princess Alexandra House DS0000014226.V299820.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. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Princess Alexandra House Address 34 Preston Park Avenue Brighton East Sussex BN1 6HG 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) 01273 565691 www.princessalexandrahouse.co.uk Mrs Carole Franklin Mrs Carole Franklin Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is eighteen (18) Service users must be older people aged sixty-five (65) years or over on admission 10th November 2005 Date of last inspection Brief Description of the Service: Princess Alexandra House is a care home registered for eighteen (18) places for people over sixty-five (65) years of age. No nursing care is provided at this home. District nurses will provide nursing input for those residents requiring this. Princess Alexandra House is located in a quiet residential area of Preston Park. Residents’ bedrooms are located over three floors. There is a passenger shaft lift that accesses all floors. There are fifteen (15) rooms for single occupancy, of which eleven have en suite facilities. There are three (3) double rooms, all provided with en suite facilities. All rooms are currently being used for single occupancy. There are suitable numbers of toilet and bathing facilities located throughout the home to meet the needs of residents. There is a good-sized dining room and lounge room. Residents have access to a well-maintained garden area. There are some local amenities in the area and there is nearby access to public transport. There is free parking available in adjacent streets to Princess Alexandra House. Weekly fees range from £298.70 to £525 per week. There are additional fees; hairdressing (shampoo and set £6), chiropody (£8), newspapers/magazines and personal toiletries (at cost). This information was provided to the CSCI on the 25 June 2006. Prospective residents find out about the home through social services referrals, word of mouth and from themselves/relatives living in the area. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Princess Alexandra House will be referred to as ‘residents’. This unannounced key inspection took place over seven hours on the 20 December 2006. Five residents, of both genders, were spoken with during the inspection. All residents were offered an opportunity to speak to the Inspector. Eight resident surveys were sent to the home of which four were returned. Three care plans were viewed and specific areas of care were looked at in one other care plan. The Registered Manager, deputy manager and four staff members were spoken with during the inspection. Eight staff surveys were left at the home of which one was returned. There was some confusion about the nature of the staff questionnaires sent by CSCI and as a result few staff completed them. Three staff files were inspected. Ten relative/visitors comment cards were sent to the home prior to inspection. None of these were returned. Out of five GP comment cards sent out prior to inspection, three were returned. A comment card was sent to a Community Psychiatric Nurse (CPN), this was not returned. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Fire records, accident records and medication procedures were inspected. The quality assurance system was discussed and complaint records were inspected. Previous requirements and recommendations at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the preinspection questionnaire. There were 13 residents residing at the home on the day of the inspection. What the service does well: Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are respected. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 6 Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home. Residents are provided with regular fulfilling activities. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Residents and staff benefit from supportive and approachable management within the home. Procedures in place for the handling of personal allowances ensure residents’ finances are safeguarded. What has improved since the last inspection? What they could do better: Thorough pre admission assessments need to be undertaken to evidence that the home can meet all of the assessed needs for prospective residents. There are plans to change the care plan format. Care plans must cover all aspects of health, personal and social care needs and provide staff with clear and up to date information on how to meet these assessed needs. Urgent action is required to ensure that clear and accurate records are maintained for the administration of medicines, ensuring residents medical needs are met and staff are safeguarded. It is recommended as good practice that handwritten prescriptions on Medication Administration Records (MAR) charts be checked and double signed by two staff who have undertaken medication training and that any hand written amendments on MAR charts are signed. It remains an outstanding requirement that robust recruitment procedures be followed to ensure that residents remain safeguarded. It is required that the home removes all door wedges and consult with the fire authority regarding suitable measures to take in regards of ‘propping open’ fire doors. Other minor shortfalls that have not been reflected as recommendations have been highlighted throughout the inspection report. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 7 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. Princess Alexandra House DS0000014226.V299820.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 Princess Alexandra House DS0000014226.V299820.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 & 6 ‘Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.’ Resident’s needs are at risk of not being met due to insufficient information being obtained by the home prior to admission. Prospective residents are provided with an opportunity to ‘test drive’ the home. Intermediate care is not provided. EVIDENCE: The pre-inspection questionnaire demonstrates that the Statement of Purpose and Service Users Guide have been amended as required at the last inspection. The content of these documents were not read. All prospective residents are assessed prior to admission. Information is obtained from other health professionals wherever applicable. The pre admission assessments viewed require to be expanded. Important medical information for one resident was not reflected in the pre admission assessment. The person undertaking the pre admission assessments must ensure these are signed and dated. Pre admission assessments did not Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 10 contain enough information for the home to evidence that all needs can be met at the home. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community or social/cultural/religious groups with any specific needs or preferences. Staff individually and collectively have the skills to deliver the services and care which the home offers to provide. Residents/relatives are provided with an opportunity to visit the home prior to admission. One comment from a resident was ‘I came for two weeks and have been here for four years’. Other residents spoken with confirmed that they or a relative had visited the home prior to admission. The resident surveys received demonstrated that they received enough information about the home before they moved in so they could decide if it was the right place for them. The home does not have dedicated accommodation to provide intermediate care. Respite care is provided if there is a spare place available. Princess Alexandra House DS0000014226.V299820.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 ‘Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.’ Residents’ needs are at risk of not being met due to insufficient information in care plans. Residents and staff are not safeguarded by the medication procedures in place. Residents are treated with respect. EVIDENCE: The Registered Manager confirmed that the home will be implementing a new care plan format. The care plan format currently in use does not provide care staff with sufficient guidelines on how to meet the assessed needs of the individuals. The care plans viewed were not being completed effectively and some contained conflicting information that had been obtained in the pre admission assessment. There was a descriptive brief summary in place on the preferred daily routine of individual residents. Specific areas of care for some individuals were not being recorded in care plans. Shortfalls were discussed with the Registered Manager on the day of the inspection. Care plans must reflect actual current practice. There was evidence that care plans are generally being reviewed on a monthly basis. The Registered Manager confirmed that Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 12 relatives/representatives are invited to be involved in the six monthly reviews of the their friend/relative, if the resident wishes them to be involved. Residents spoken with all confirmed that their personal care needs are being met at the home. All resident surveys received demonstrate that they receive the care and medical support they need. GP comment cards showed that staff demonstrate a clear understanding of the needs of residents. A GP was called to the home on the day of the inspection. One comment from a GP was ‘excellent level of care’. The Registered Manager confirmed that there are no residents with pressure sores and the home has access to pressure relieving equipment when needed. No nutritional assessments are undertaken. Two residents observed to be wearing glasses confirmed that eye checks are undertaken when needed and residents are assisted to see health professionals when the needs arise. The deputy manager confirmed that there are policies and procedures in place for all aspects dealing with medication. The content of these were not read. There were concerns noted with the procedures in place for dealing with medications. The Medication Administration Record (MAR) charts in use had just commenced for the month. On inspection, it was noted that there was medication being signed for and not given and medication given and not signed for. The Inspector could not work out one individuals MAR chart and tablets being held at the home and the deputy manager was unable to provide any explanation to the Inspector as to the administration process for this individual. There were no controlled drugs being held at the home at the time of the inspection. Codes being written on MAR charts were not being explained and no reasons were being provided why medication had not been administered. One MAR chart had medication signed for a time that had not yet passed. It was confirmed that records are being kept on all ingoing and outgoing medicines. Residents are provided with an opportunity to self medicate, based on a risk assessment being undertaken. A medication risk assessment viewed had not been reviewed for over 12 months. It was discussed with the deputy manager that these are kept under regular review and that information is provided in the care plan regarding the exact level of self-medication for the individual. It is recommended as good practice that all hand written prescriptions are double signed by two staff who are medication trained and any hand written amendments are signed. There was evidence that the timing of medication is to the individual’s preference. One resident informed the Inspector that the home had been accommodating and understanding in their requirements of receiving medication at specific times. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 13 All residents spoken with confirmed that their privacy and dignity are respected. It was confirmed by residents and observed by the Inspector that staff knock on residents’ room doors prior to entering. Staff were observed to have a good professional rapport with the residents and were heard to be calling by their preferred term of address. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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.’ Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents’ choice and preferences are catered for at meal times. EVIDENCE: Residents and staff spoken to felt there was a good activities programme in place. The Registered Manager confirmed that residents from Princess Alexandra House and another care home within the area will visit each other’s homes to participate in a variety of activities. The two homes were having a sherry and Christmas carol singing morning on the day of the inspection. Family members had also been invited to attend this activity. There is an activities co-ordinator employed at the home that works two days a week. Staff provide activities on the days that the activities co-ordinator is not working. Three resident surveys showed that there are always activities arranged by the home that they can take part in. One comment written was ‘I’m very pleased with the activities’. Residents spoken with confirmed that their lifestyle within the home is their choice. They choose what to wear and when to get up and go to bed etc. Residents are encouraged to bring in personal possessions with them to Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 15 personalise their own rooms. Residents felt that living at the home was like having an ‘extended family’. Residents are encouraged to continue with activities they may be involved in within the community prior to admission. There are no restrictions imposed on visiting relatives/friends. Residents spoken with were complimentary about the food provided. The Inspector enjoyed a roast meal with the residents for lunch. Residents were observed to be enjoying the meal and lunchtime appeared to be a social time and was unhurried. Staff were observed to be nearby to offer discreet assistance should anyone require assistance. Two cooks were spoken with on the day of the inspection. It was confirmed that there was no resident currently residing at the home with specific dietary requirements. There is a book accessible to residents to write in if they have any special requests of meals. There is a list of residents’ likes/dislikes provided to the cooks to ensure residents choice and preferences are catered for. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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.’ Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Safeguarding Adults procedures and training of staff ensure residents are safeguarded from abuse. EVIDENCE: The home has a suitable complaints procedure that all involved with the home has access to. No complaints have been made directly to the CSCI. There has been one complaint made directly to the home since the last inspection. Records are maintained of complaints and what action is taken. Records demonstrate that the home investigates these in an unbiased manner. Residents surveys received demonstrated that residents know who to speak to if they are not happy about something and know how to make a complaint. Of the residents that were asked, all confirmed that they know who to speak to if they had any concerns and feel comfortable making complaints. It was confirmed that there is a policy and procedure in place for dealing with allegations of abuse. The content of this was not read. There have been no allegations made since the last inspection. Staff spoken with confirmed that they receive Safeguarding Adults training and are aware of the procedures to follow in the event of an allegation of abuse being made. The Registered Manager confirmed that she has attended the local authorities Adult Protection training designed for managers. Princess Alexandra House DS0000014226.V299820.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 ‘Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.’ Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: Rooms are located over three floors and there is a passenger shaft lift available to assist residents to access all areas of the home. There is also a stair lift present to access a mezzanine floor. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Residents confirmed that they were happy with their rooms. Two residents wished to show the Inspector their room. These were observed to be personalised to reflect the personality and character of the individual. Residents spoken with confirmed that they were able to bring personal items with them when moving into the home. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 18 The pre-inspection questionnaire demonstrates that a variety of decoration and changes in the environment has been implemented since the last inspection. The environment was observed to be well maintained. The home was clean and free from offensive odours on the day of the inspection. Residents’ surveys demonstrate that the home is always fresh and clean. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for infection control and a company is contracted to dispose of any soiled waste/clinical waste. Princess Alexandra House DS0000014226.V299820.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 ‘Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.’ Residents’ needs are currently being met with the number and skill mix of staff on duty. Residents would be better safeguarded if robust recruitment procedures were followed. Staff are trained and competent to do their jobs. EVIDENCE: Residents were very complimentary about the staff working at the home. Staff spoken with confirmed that they enjoy working at the home. The staff survey received stated ‘ Nice atmosphere and work conditions, like family home’. All residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. There are usually two staff working day time hours, plus management and one waking night carer. There are all female staff working at the home. Male residents confirmed that this was not an issue for them. Comments received about the staff ranged from ‘very good’ to ‘excellent’. There are ten care staff employed at the home, of which four have obtained National Vocation Qualification (NVQ) level 2 or above. An additional two staff are currently undertaking NVQ level 2 studies and a further staff member is commencing these studies in the near future. Three staff files inspected demonstrated that robust recruitment procedures had not been followed. All three staff had commenced employment without a Protection of Vulnerable Adults (POVA) and Criminal Record Bureau (CRB) Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 20 having been received prior to commencing employment. An explanation was provided for one staff member. One staff members file could not be located on the day of the inspection, however the Registered Manager assured the Inspector that all recruitment checks have been undertaken for this individual. References are obtained on all prospective employers and detailed application forms are completed. There was very limited information obtained regarding staff’s health status. The home must ensure that all workers are physically and mentally able to carry out their duties. Staff spoken with confirmed that they are kept up to date with all mandatory training and are provided with enough training opportunities. Recent training undertaken included: POVA, manual handling, infection control, first aid and fire training. The home has an induction programme in place and has information available on the new Common Induction Standards that have been newly implemented. A carer, who had no previous care working experience, confirmed that they felt the induction process was good. Princess Alexandra House DS0000014226.V299820.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 ‘Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.’ The home is generally run in the best interest of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The Registered Provider is also the Registered Manager. Staff spoken with were very complimentary about the Registered Manager at the home and find her approachable and supportive. They were also complimentary about the deputy manager in post. The Registered Manager is registered with the CSCI and has completed NVQ level 4 in care and the Registered Manager Award course. The Registered Manager confirmed that there is a quality assurance and quality monitoring system in place where regular feedback is sought from residents, Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 22 district nurses and GP’s. Relatives and visitors are spoken with when they visit the home. Resident and staff meetings are held twice a year and a newsletter is produced by the home every quarterly. The Registered Manager confirmed that she will be reassessing the quality monitoring system currently in place to ensure it assist in obtaining the information that will be needed in the changes to the CSCI inspection process. The Registered Manager is an appointee for one resident. The home collects this individuals’ pension and ensures the resident receives their weekly allowance. No personal allowance is held for residents at the home. All residents residing at the home have made their own arrangements in dealing with their own finances. The Registered Manager and staff spoken with all confirmed that all staff are kept up to date with mandatory training. The pre-inspection questionnaire demonstrates that fire alarms are tested weekly and a fire risk assessment was undertaken in October 2006. It was discussed with the Registered Manager that door wedges must not be used. The home needs to consult with the local fire authority regarding other safety devices that are suitable for use. Action must be taken to ensure that suitable measures are in place for the laundry, as this is a higher risk area for fires to commence. Hot water taps were noted to be regulated and windows were restricted. No other health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP3 OP7 Regulation 14(1) 15(1) Requirement That thorough pre admission assessments are undertaken for all prospective service users. That care plans cover all aspects of health, personal and social care needs and reflect actual current practice. That clear records be maintained of all medicines administered at the home. That recruitment of staff must comply with the Care Homes Regulations 2001. (Timescale 10.01.06 not met) That advice be sought from the fire authority regarding the ‘propping open’ of fire doors. That fire doors are not wedged open. Timescale for action 15/02/07 15/02/07 3. 4. OP9 OP29 13(2) 19(1)(a) (i) Schedule 2 23(4) 23(4)(a) 15/01/07 15/02/07 5. 6. OP38 OP38 15/02/07 15/01/07 Princess Alexandra House DS0000014226.V299820.R01.S.doc Version 5.2 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. 3. Refer to Standard OP8 OP9 OP9 Good Practice Recommendations That nutritional assessments be undertaken. To have written documentation to clarify the exact level of self-administration. That handwritten prescriptions on MAR charts be checked and double signed by two staff who have undertaken medication training. That any hand written amendments on MAR charts are signed. 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