Care Home: Alexandra Grange

Annual service review Name of Service: Alexandra Grange The quality rating for this care home is: The rating was made on: three star excellent service 0 1 1 0 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: John Mullen Date of this annual service review: 0 6 1 1 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service Address of service: Howard Street Pemberton Wigan Lancashire WN5 8BD 01942215222 01942735555 judithmelling@cuerden.com Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia Conditions of registration: Mr Keith Lowe Number of places (if applicable): Under 65 Over 65 52 0 The registered person may provide the following category of service only: Care home with nursing - Code N. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Dementia Code DE. The maximum number of service users who can be accommodated is: 52. Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Alexandra Grange is a care home situated within the Pemberton area and is close to local shops and other facilities nearby. Public transport is easily accessible. Access to the motorway network is also nearby. The home is purpose built and all personal accommodation is provided in single rooms each with an en suite facility. Accommodation is provided on two floors with a passenger lift allowing access to the upper floor. The home provides personal care and nursing care for male and female service users over the age of 60 with dementia. 0 1 1 0 2 0 0 8 Annual Service Review Page 2 of 6 The fees at the time of the last key inspection ranged from 376.23 to 415.00 pounds. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review: What did we do for this annual service review? The annual service review for Alexandra Grange Care Home included the following: An annual quality assurance assessment (AQAA) was sent to us by the service. The AQAA is a self assessment and a data set that is filled in once a year by all providers and is one of the main ways that we get information from providers about how they are meeting outcomes for users of their service. The AQAA also provides us with statistical information about the individual service, trends and patterns in social care. Surveys of staff, users of the service and their relatives. A review of what the service has told us about since the last key inspection. A review of the findings of the last key unannounced inspection. What has this told us about the service? The AQAA was completed to a good standard and returned promptly. It showed that the home seeks the views of users of its service and has amended its practices as a result of consultation. Throughout the AQAA there is a commitment to a full quality assurance system which it is seeking to expand as a means of continual improvement. The AQAA shows that the home has updated its Statement of Purpose to reflect its current aims and objectives. It shows that there has been improved training for staff, particularly in the area of the Mental Capacity Act and Deprivation of Liberty to confirm that current legislation is being correctly imparted to staff. The AQAA states that it has increased staffing to reflect the high level of dependency amongst people living there. The home has a wide range of activities, based on a full time Activities Organiser, and has been changing activities in response to changing demands. It reports a continuing commitment to improve the environment through a redecoration programme and through ongoing refurbishment. The AQAA confirms that full policies and procedures are in place to protect users and that the complaints procedure is both fully publicised and has been reviewed this year to ensure it is up to date. The AQAA confirms that the home has full policies and procedures to underpin practice. It states that there have been six complaints all of which have been dealt with within the required time frame and only one of which has been upheld. It states there have been two safeguarding issues which a review of the service folder confirmed has been referred to us as required. There was a good response to the surveys sent to interested parties. Overall, the surveys were positive about the home with some exceptions to this. One user said all the things in the home are nice, I like it here and a member of staff said good home, good staff, good courses and training. However, within the context of very positive comments from staff there were questions about the lack of equipment in the home, the twelve hour shifts that are undertaken and the need for an registered mental nurse Annual Service Review Page 4 of 6 to assess users of the service. The son of a user was very positive about the home but did state there was a need for improved decoration in certain areas of the home. The conclusion from the surveys was that, generally, the home is of a good standard but that there are specific areas that need addressing. A review of the evidence since the last key inspection has found that most notifications have been routine and confirmed that the home was notifying us as required. As noted previously, the two instances of safeguarding were referred to us as required and showed that the home dealt with these matters appropriately. There was one complaint which had been sent to us and this, again, was dealt with appropriately. However, recently there has been another concern sent to us from a former member of staff which states that inappropriate admissions are being made, resulting in difficulties for the home. It also states that the registered mental nurse is not giving the required input into the assessment of people living in the home. Since then, the registered manager has produced a very detailed response to this complaint in which she refutes these allegations and states that a full assessment is made. There has not been a need to visit this service thus far since the last key inspection. A review of the findings of the last key inspection confirmed that this home has been rated a three star, excellent service. Of the seven outcome groups four were assessed as good and three as excellent. The inspection only resulted in one requirement. What are we going to do as a result of this annual service review? The annual service review has show some very positive outcomes for users of the service. The AQAA, the surveys and the review of the service folder have shown evidence of a progressive, professional service. However, the review has also revealed some areas that need to be kept under consideration due to the concerns expressed. The Care Quality Commission will continue to monitor information about this service and will carry out an inspection when required. We can inspect the agency at any time if we have any concerns about the quality of the service or the safety of the people using it. Annual Service Review Page 5 of 6 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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