Care Home: Alexander Court Care Home

Similar services:

• Claremont House
• Oak Ridge
• Sun Court Nursing Home
• Ashville House
• Bilney Hall
• Hill Barn
• Mabbs Hall Nursing Home
• Henrietta House

What the care home does well What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Alexander Court Care Home Raymond Street Thetford Norfolk IP24 2EA Lead Inspector Mr Jerry Crehan Unannounced Inspection 11th June 2008 09:15 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 Alexander Court Care Home DS0000065309.V366279.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. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander Court Care Home Address Raymond Street Thetford Norfolk IP24 2EA 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) 01842 753466 01842 753467 alexandercourtnh@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Rachael Claxton Care Home 47 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (18) of places Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person with the category DE for the duration of that person`s residence and until that person reaches the age of 65; once either scenarios occurs this category will lapse and the registration will revert to DE(E) 29. 3rd December 2007 Date of last key inspection Brief Description of the Service: Alexander Court is a purpose built care home providing residential care for up to 47 older people, 29 of whom may have a diagnosis of dementia. Built in 1998, the home is situated in the town centre of Thetford giving easy access to local shops and other community facilities. The accommodation is provided on two floors serviced by a shaft lift and stairs. All rooms are designed for single occupancy and contain en-suite toilets and wash hand basins. There are enclosed patio areas and grounds. Alexander Court is one of several homes in Norfolk owned by the proprietors. The range of weekly fees for care at the home is £341 to £600. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use the service experience good quality outcomes. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. This report gives a brief overview of the service and current judgements for each outcome group. Before the inspection the manager of the service completed a lengthy questionnaire (Annual Quality Assurance Assessment) about the service referred to within the report as the ‘AQAA’. To complete this inspection we looked at information within the AQAA document, information from a pharmacy inspection undertaken on 13th February 2008 by the Commission’s pharmacist inspector, and other information collected since the last inspection. We conducted an unannounced site visit that took place over 7.45 hours on 11th June 2008. Opportunity was taken to tour the premises, look at care records and policies, and communicate with residents, visitors, staff and the Manager. We observed daily life in the home and what was happening for the people who live there. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. Due to the varying degrees of cognitive impairment it was not always possible for people who live at the home to tell us what life in the home is like. We compared care records and discussion with staff and visiting relatives (where possible) against observation of those individuals. Following the conclusion of the adult protection investigation into alleged medicine mismanagement and neglect at the home carried out by the Norfolk Constabulary, and the subsequent pharmacy inspection on 13th February 2008, the Commission agreed with the home’s Proprietor and with the Adult Social Services Department to the ending of the voluntary suspension of admissions to the home for new residents from 14th February 2008. The day and night time staff complement will need to increase as resident numbers increase. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 6 What the service does well: • • People living in the home experience good outcomes as their health and care needs are properly assessed, met and reviewed regularly. Care practice observed during the visit was good. Care staff were caring, respectful and attentive in their approach to residents. Residents were complementary about the care they received from staff. The social and recreational activities on offer at the home (and supported by the home within the local community) are suitable and sufficiently varied meet individual’s needs and expectations. Residents continue to say how much the social activities have improved since the activities coordinator commenced. A monthly newsletter (from June) now produced by the home advertises forthcoming events and contains other news associated with the home helping to keep people in touch with aspects of life there. People who use the services have access to a good diet and meals that are well prepared and served in congenial surroundings. Sample staff files and discussion with staff provided evidence that residents are protected by good staff recruitment practices. The well-being of residents is maintained and their relatives have confidence in the care provided because the manager shows strong leadership and that she is committed to providing good quality care. • • • • • What has improved since the last inspection? • Medication management and administration at the home has improved and medication practices reviewed safeguard the health and welfare of people who use the service. There is now dedicated communal space in which residents can meet their visitors privately. This area is well furnished and conducive for residents to receive visitors. There have been several environmental improvements, including the redecoration and re-carpeting of large parts of the home and the replacement of furnishings and bedding. The communal and hallway areas on the first floor of the home offer more interest and stimulation to residents. DS0000065309.V366279.R01.S.doc Version 5.2 Page 7 • • Alexander Court Care Home • A significant number of staff have undertaken dementia awareness training they need to assist them in offering the specialist care required by residents. There are improved numbers of staff qualified as ‘appointed persons’ in providing first aid. • What they could do better: • • Care records and recording should be improved e.g. bathing records and records of activities residents have participated in. Some care plans contained additional information about the residents’ background in the form of a ‘life story book’ that can usefully assist the care staff to build a relationship with residents as individuals, though several care plans for residents with dementia do not. The manager should extend training in the safe handling of medication to all senior care staff and to other staff as appropriate. Ensure the safety of residents through following correct health and safety procedures regarding storage of cleaning products. These should not be left or temporarily stored in communal parts of the home. To ensure that the mental health needs of people using the service are met there should be qualified staff in providing dementia care, in addition to those who have received ‘awareness’ training. • • • 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. Alexander Court Care Home DS0000065309.V366279.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 Alexander Court Care Home DS0000065309.V366279.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): Standards 1 & 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents have their needs assessed and access to all of the information they need about the service they may choose so they can make an informed choice. EVIDENCE: The provider has a ‘Statement of Purpose’ and ‘Service User Guide’ to reflect the services provided at the home. These documents contain sufficient information for anyone to make an informed choice about long-term care. The Service User Guide contains a summary of the home’s complaints procedure. There is a policy and procedure in place for assessing and admitting people to the home. There is evidence of assessment for residents’ recently admitted seen in their files. These include an assessment of the prospective resident’s healthcare and social care needs, and any relevant history or diagnosis prior to Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 10 their moving to the home. The assessments seen in the files inspected formed the basis of individual care planning and risk assessment for care staff to follow. Alexander Court Care Home DS0000065309.V366279.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): Standards 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home experience good outcomes in this area as their health and care needs are properly assessed, met and reviewed, though care records and recording should be improved. Medication management practices safeguard people’s health and welfare. EVIDENCE: A sample of care records relating to people who live at the home were looked at and these were compared against observations of those residents. The care records contained care and health assessments that provided staff with clear guidance as to how people’s needs, such as mobility indoors and outdoors, pressure area care, nutrition and continence should be met. There was evidence that records had been reviewed and updated regularly, and that reviews have included input from residents and their relatives. Observations of residents showed that recorded care plan guidance was being followed by staff, Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 12 for example in mobility care plans for a resident going out of the home and for another resident mobilising indoors. Two care records seen provided evidence of infrequent baths or showers for these residents, with no bath provided in June and a maximum of two baths each month in recent months. The manager and staff stated that more frequent baths have been provided, though evidence of this was not recorded. The care records seen contained some personal and family information and some records contained a comprehensive ‘life history’ document to assist carers in providing appropriate care to the resident as an individual. However, other care records looked at for people with dementia contained little information about how to meet people’s individual social and emotional needs, and contained no life history information. Staff spoken with said that care records provide them with guidance as to how residents’ needs should be met. Care delivery observed during the inspection visit was good. Carers’ interaction with residents was caring and courteous. Residents spoken to during the inspection visit spoke favourably about care staff and the quality of care they provide. Comments from residents included ‘I’m getting on very well here – much better than I was at home’ and ‘staff are nice and helpful’. Comments from relatives included ‘Carers very helpful’ and my relative ‘is always well dressed and always clean’. There was evidence in care records and from staff that community healthcare services such as G.P, nursing, chiropody, optical, and psychiatric services were sought for those who required these. The completed AQAA provided by the manager states that ‘All our residents are registered with a local doctor and have access to a G.P 24 hours a day’ and ‘Any emergencies are dealt with quickly with very good support from other healthcare professionals’. A pharmacy inspection was undertaken on 13th February 2008 by the Commission’s pharmacist inspector. Overall, this audit represented an improved outcome for residents at the home. Ways in which the improvement could be sustained were discussed with the manager during this visit. A further inspection of the medication standard was undertaken. The home has a suitable policy for dealing with the control and administration of medicines that staff are aware of and work to. This includes supporting residents to look after and administer their own medicines where they have the capacity to do this. Medication records reviewed were up to date for each resident indicating medication received and administered or disposed of, individual records seen carried resident identifying photographs to assist in safe administration. Sample audits of medication were undertaken and records tallied with medication held. There are clear guidelines for care staff in the event of administration of ‘PRN’ (when required) medicines. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 13 The completed AQAA provided by the manager states that the home could do better by providing ‘Medication training for all staff’. Training information provided by the manager indicates a total of eight staff have completed ‘Safe Handling Medication’ training and that several other staff, including senior care staff have not. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have access to a good diet and meals that are well prepared and served in congenial surroundings. The social and recreational activities on offer at the home are suitable and sufficiently varied meet individual’s needs and expectations. EVIDENCE: Residents spoken with during the visit stated that there are activities on offer to choose from, one person spoken with said that they had ‘Had visitors today – we can meet in the new room, but used mine today. I go out to the library once a week and keep busy with other activities like painting and singing’. Another comment indicated ‘It’s not the same as home and I miss my cat and garden, but I like to go out into the garden here’. A dedicated activities coordinator working at the home provides a weekly calendar of activities. A garden party taking place the weekend after the inspection visit was also advertised. A monthly newsletter now (from June) Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 15 produced by the home advertises forthcoming events (including the garden party) and contains other news associated with the home. There are bookshelves in lounges with books and music tapes, and artwork and photograph collages on walls display scenes of past activities undertaken. Residents were observed participating in activities within the home during the visit, and some residents were supported by the home’s activities coordinator (or visiting relatives) in trips outside of the home to local community facilities, such as the library. The manager stated that the local vicar visits on some afternoons and that residents can participate in prayer and song. The manager also stated that the Catholic priest visits so that residents can take Holy Communion if they wish. The bedrooms seen on the day of the inspection visit were well furnished and equipped to suit the residents’ daily lifestyle and reflect their personal choices and preferences. As indicated by a resident in a comment above, the manager has adapted accommodation on the ground floor of the home to provide a new meeting room with television, DVD, video, two settees and chair. The manager said that a family were planning to play their holiday DVD to their relative at the home. A well-cooked and well-presented main meal was provided. The main lunch option was roast chicken, potatoes, and vegetables. Quiche was the main alternative, which some residents had opted for. Apple tart was available for sweet. Dining tables were nicely set with glasses, placemats and serviettes to help provide a congenial setting. Lunch was served by care staff and taken by residents who were able to take their time over their meal. A resident and visiting relative both commented that the ‘food is excellent’. The AQAA document provided by the manager indicated that residents ‘have the choice of eating in the dining room together or if they prefer, in the privacy of their own room’. There was evidence that residents’ do make their individual choice about where to take their meal, and that they receive the support they require at mealtimes. There is a servery in the dining area stocked with choice of breakfast cereals, biscuits, soft drinks, wine and fruit. There is also a Microwave and fridge in this area to make taking snacks convenient and easy. Two residents spoken with said that they were ‘very happy here’, ‘we’ve got everything – we’re very lucky’. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for responding to the concerns and complaints of people who use the service are good. The procedures and practices in place help ensure people who use the service are protected from abuse. EVIDENCE: The manager keeps a record of complaints, though stated that she has received verbal complaints only since the last inspection visit. The home has a detailed complaints procedure and information on how to make complaints is detailed in the home’s guide for residents. The Commission has not received complaints about the service since its last inspection. Residents spoken with during the inspection visit stated that they would be happy to speak with carers if they had a concern or complaint. One resident remarked that they had ‘no complaints or worries – but if I did I would speak to the manager or to the staff’. A comment card received from a relative indicated that they ‘know how to make a complaint about care provided at the home if they need to’. Other relatives who commented indicated that they felt that the manager was approachable and that they knew how to make a complaint if needed. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 17 The staff spoken with during the inspection visit were clear about the action they would take if concerned about the possibility of abuse taking place at the home and were confident that they could deal with this appropriately. They were sufficiently aware of the home’s ‘Whistle-blowing’ procedure and its function. The majority of staff have undertaken ‘Protection of Vulnerable Adults’ (POVA) training. The adult protection investigation into alleged medicine mismanagement at the home and wilful neglect lead by the Norfolk Constabulary has concluded. Two former staff received cautions. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 18 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, 22, 24 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home has been improved since the last inspection. The environment at the home is well maintained resulting in people who live in the home having a safe internal and external environment to live in. EVIDENCE: A tour of the premises was completed. Since the last inspection a number of improvements have been made including the redecoration of the reception area and much of the ground and first floors. A relative commented that their parent’s ‘bedroom is nice – much nicer decorated at the home now’. New carpets have been provided in the ground floor corridor and in lounges both upstairs and downstairs. The activities room on the first floor has been revamped. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 19 A cleaning trolley with cleaning materials/products was seen stored (temporarily) in an unlocked communal bathroom on the first floor of the home presenting a risk to residents there. The matter was brought to the manager’s attention to deal with at the time of the inspection visit. Bedroom accommodation seen was personalised and furnished to a good standard with new curtains and duvets in the process of being changed and bedrooms in the process of being redecorated during the inspection visit. The corridor on the first floor has added interest for residents with a wide selection of pictures throughout. There was evidence of signage to support residents in recognising their way around the building and some identifying the communal bathrooms, though one bathroom on the first floor was not identified, and this was brought to the managers attention. Signage was also used to support residents within their own accommodation; an example of this was a sign to remind a resident not to leave their bedroom without their walking frame. Doors to residents’ private accommodation are lockable, and residents have lockable facilities within their bedrooms for valuables. As indicated above there is now dedicated communal space in which residents can meet their visitors privately. At the time of the inspection visit to the home there were four portable hoists and one stand aid in working order. Staff confirmed that this was adequate to meet the needs of residents. There is other specialist equipment in evidence at the home such as assisted baths and pressure mats. Outside there is a sensory garden with raised beds and solar lighting, which was frequently used by residents during the inspection visit. A smoke hut is available in the patio area. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are deployed in sufficient numbers to support the needs of people who use the service, though there is a shortfall of staff with specialist training in dementia care. EVIDENCE: There were 39 residents accommodated at the home at the time of the visit. There is a total care staff complement of 29 staff in addition to ancillary staff and the manager. From observation and from information provided by the manager there are 7 care staff throughout the day and 4 care staff are on duty at night. These allocations include deputy manager, team leader or senior carer on duty. Observations showed the numbers of staff on duty during the inspection were sufficient to meet the needs of the 38 residents currently accommodated. However, one comment card received from staff prior to the inspection visit indicated a view that ‘we need more staff as it’s a struggle’. It was observed that call bells used by residents did not ring for long when attention from staff was required. Staff were respectful in their approach and clear in their communication with residents. Staff also responded appropriately to residents who were communicating a need for activity and stimulation. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 21 From information provided by the manager and training records, there is a low percentage (21 ) of care staff that have gained their NVQ level 2 in care or above. Six care staff currently hold a qualification at NVQ 2. A further twelve care staff are either currently undertaking or have registered to undertake the training. A review of sample staff files provided evidence that residents are protected by good recruitment practices undertaken by the manager and proprietor. Information from training records and discussion with staff provided evidence of a good approach to training, with staff having achieved mandatory training in sufficient numbers. There are six ‘appointed persons’ in first aid provision, the Manager stated in the AQAA for the home that this will increase but is currently adequate to provide an appointed person per shift. There is a rolling cycle of staff training that addresses mandatory and other training requirements provided by the proprietor. Within the last year the majority of care staff have undertaken dementia awareness training. There is no evidence to show that staff have had training to a higher level in dementia care. However, the Manager stated that care staff would receive a three-day specialist dementia training course later this year. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 22 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): Standards 31, 32, 33, 35, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is experienced to run the home. Management systems are in place to measure success in meeting the aims and objectives of the home, and to ensure consistency in safeguarding the health of people who use the service. EVIDENCE: The Registered Manager has completed the Registered Managers Award, and has NVQ level 4 in Management. She has many years of experience as both a proprietor and manager of services for older people. Whenever the manager is away from the home the deputy manager or one of the two team leaders is in charge of the home. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 23 The manager was described by staff and relatives as ‘approachable’; one relative spoken with added that they felt they ‘can go away on holiday now without worrying’, and that they were ‘very happy with care and improvements at the home’. There is an on-call system at weekends when senior staff are in charge of the home. The system provides access to the manager or deputy, and to an area on call support system operated by the proprietor. The manager has several processes at the home for monitoring the quality of the service it provides. She arranges residents, relatives and staff meetings, this was confirmed when speaking to a variety of people during this site visit. The Manager stated that all staff have been surveyed for their views and analysis of results shared in staff meetings and used to inform improvements to the home. Satisfaction surveys for residents, relatives and other ‘stakeholders’ are due to be repeated in July 2008 according to the manager. Relatives or appointees manage most residents’ financial affairs. Financial records reviewed were satisfactory and are evidently audited periodically for the protection of residents and staff. Maintenance records seen were satisfactory. There is relevant mandatory training for staff, including health and safety and fire training. Alexander Court Care Home DS0000065309.V366279.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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Alexander Court Care Home DS0000065309.V366279.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 OP7 Regulation 16.2(m)(n) Requirement People who live in the home must have their social and emotional needs assessed and written into an individualised plan so that staff know how their needs should be met. People who live in the home must be supported to bath regularly and records of this must written into their plan of care. Staff authorised to handle and administer medicines must have received robust training and be regularly assessed as competent to undertake medicine management tasks. People who live in the home must have an environment that is free from hazards to their safety so that they are protected from harm. Staff must receive suitable dementia care training to ensure that the mental healthcare needs DS0000065309.V366279.R01.S.doc Timescale for action 31/07/08 2. OP8 12.1(a) 11/06/08 3. OP9 18.1 31/08/08 4. OP19 13.4(a) 11/06/08 5. OP30 18.1(a) 31/10/08 Alexander Court Care Home Version 5.2 Page 26 of people using the service are met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations It is recommended that all care staff are supported to undertake NVQ 2 (or above) training to update their skills. Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Alexander Court Care Home DS0000065309.V366279.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!