Care Home: Alexandra House

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What the care home does well There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was very friendly and respectful, that there were no rules and they were encouraged to retain their independence. Facilities used by residents are generally comfortable and homely. Staff are encouraged to have training to equip them to meet residents needs and have supervision to support them in their jobs. Residents and staff thought that the management were doing a very good job in that they were friendly and efficient. Management were keen to rectify issues as quickly as possible. What has improved since the last inspection? Staff do not commence employment until the return of two references have been received. Serious issues appertaining to the welfare of residents are reported to the Commission for Social Care Inspection so that the service`s performance can be monitored What the care home could do better: CARE HOMES FOR OLDER PEOPLE Alexandra House 1 Narborough Road Huncote Leicestershire LE9 3AN Lead Inspector Keith Charlton Unannounced Inspection 17th July 2008 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 Alexandra House DS0000049312.V368517.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. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House Address 1 Narborough Road Huncote Leicestershire LE9 3AN 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 2753669 jackieskubala@hotmail.com Mrs Jacqueline Ann Skubala Mr Albert Konrad Skubala Mrs Jacqueline Ann Skubala Care Home 17 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (17), Physical disability over 65 of places years of age (7) Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To be able to admit the named person of category DE named variation application number V000000223 dated 10/12/03. Named Person To be able to admit the person of category SI(E) named in variation application No. V27292 dated 15 November 2005 5th September 2007 Date of last inspection Brief Description of the Service: This is a registered home for older people. It is situated in the village of Huncote. There are local facilities nearby. Residents all enjoy the benefit of a single bedroom with toilet en suite. There is a choice of lounges and a good sized garden to the rear. The weekly fees range from £480 to £650 - the Registered Provider provided this information on the day of the Inspection. There are additional costs for individual expenditure such as hairdressing, toiletries, etc. The home provides information to residents and prospective residents in the form of a Statement of Purpose and service users guide that describes the services it offers, and a copy of the last Inspection Report. They can be provided to enquirers upon request to give a view as to the quality of life for residents. Alexandra House DS0000049312.V368517.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 the people who use this service experience good quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is 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, discussion, where possible, with them, visitors and care staff and observation of care practices. This was an unannounced Inspection. The Registered Provider was present and helped in carrying out the inspection. Planning for the Inspection included looking at notifications of significant events sent to the Commission for Social Care Inspection and the issues contained in the previous Inspection Report. There have not been any complaints made to the Commission for Social Care Inspection about the service since the last inspection. The Inspection lasted six hours in total and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with eight residents, two members of staff, one visitor, a visiting GP a Registered Provider, Mr. Albert Skubala and the Deputy Manager. What the service does well: There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was very friendly and respectful, that there were no rules and they were encouraged to retain their independence. Facilities used by residents are generally comfortable and homely. Staff are encouraged to have training to equip them to meet residents needs and have supervision to support them in their jobs. Residents and staff thought that the management were doing a very good job in that they were friendly and efficient. Management were keen to rectify issues as quickly as possible. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by staff ensuring that: The welfare of residents would be further assured by – Care Plans all have fully up to date Risk Assessments regarding residents needs, that staff read all Care Plans to ensure they are fully aware of all residents needs, that they read the Policies and Procedures of the home so as to work in a consistently high standard, that there is a written policy in place if medication is out of stock from the pharmacist, and that staff receive planned supervision to ensure they receive support to provide a consistent service. It is recommended that Residents Meetings take place to discuss relevant issues – reviewing activities, menus etc. More outings need to be provided as per residents preferences to provide more stimulation and interest for residents. The Complaints Procedure needs to be clearer for residents and their representatives so that any complaint is dealt with fully. The staff training programme is generally comprehensive though would aid staff understanding if training on all essential issues were added to the programme. Staff need to know the full Safeguarding procedure to be able to protect residents from abuse. Staff rotas need to be correct to show there is sufficient staff on duty to meet residents needs. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 7 Fire systems need to be strengthened by ensuring fire doors are kept shut where necessary and that staff are aware of the full fire procedure to protect residents from fire risks. Hot water temperatures need to be closely monitored and controlled to protect residents from scalding. 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. Alexandra House DS0000049312.V368517.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 Alexandra House DS0000049312.V368517.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission so that staff are able to meet their needs. EVIDENCE: Residents said that someone from the home came to see them before admission to discuss their needs and they were encouraged to visit. An assessment was inspected and whilst it contained good detail of relevant information as to residents needs it did not include all aspects of medical checks – dates of the last dental and optical, tests etc to ensure these are followed up in a timely manner so residents health needs are fully promoted, as per the National Minimum Standard. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 10 Assessments were seen on file – this allows staff to be aware of a new resident’s needs. The service does not offer intermediate care. Alexandra House DS0000049312.V368517.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. The individual needs and choices of residents living in the home are generally well met. EVIDENCE: ‘’I think we are well cared for here’’. ‘’If I need a doctor they will get one for me’’. No residents asked knew they had a Care Plan and no Plan seen by the inspector had a signature of a resident/representative agreeing to its contents – this needs to be followed up. Care plans and risk assessments continue to be good in general. There were a small number of gaps, for example when health checks took place – dental, Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 12 optical, hearing tests etc. This needs to be recorded so that these can be arranged at regular intervals as needed. In general residents contacts with medical personnel were well documented in Care Plans. Care plans are reviewed at regular monthly intervals and this was seen as recorded in the Plans. It is recommended that there is a record of residents full personal histories compiled so that they can be seen as individuals with a valued history. Residents said that if they were unwell and wanted to see a GP then staff would arrange this. There was evidence on residents files as to medical appointments being arranged. A staff member said she had not been asked by management to read the residents Care Plans or the Policies and Procedures of the home, which is good practice so that there is full awareness of residents needs. A visiting GP was spoken with and she was very positive that staff contacted her when needed and were professional in carrying out what was asked of them, and residents always looked to be well cared for. Another GP in a survey said that the home provides ‘’individual attention, excellent attitude, respect for clients’’. Accident records were viewed which showed that medical services were properly referred to on occasions when there had been a serious injury, e.g. head injury. The inspector observed that staff were friendly and respectful to residents and encouraged in a friendly manner at the residents pace. There were very positive comments about the staff from all parties spoken with. The visitor the inspector spoke with said she thought the staff were caring and friendly and did a good job. A staff member confirmed all staff issue medication undertaken medication training in house by the Deputy Manager and this was recorded on staff records. Medication was observed to be properly issued to residents Medication record sheets were found to be completed and up to date. No residents asked wanted to self medicate and all appreciated the staff holding their tablets and giving them at prescribed times, though records showed that independence was encouraged in that some residents applied their own creams. Medication is kept securely in the medication trolley within a locked room. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 13 The Registered Provider said there was no medication kept. A more robust cabinet is required for special medication if they are kept in the future. The Deputy Manager was in the process of reviewing medication Policies and Procedures and is to add a procedure as to what action staff need to follow if medication does not arrive at the home in time from the pharmacist. Alexandra House DS0000049312.V368517.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): 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 living at the home have opportunities for activities and outings though this needs extending, and meals continue to be seen as good. EVIDENCE: ‘’We get enough activites here but it would be good to have more activities’’. ‘’I like the activities they do on a Monday, Tuesday and Thursday here’’. ‘’The food is good and we get a choice but I would like some salt added to make food more tasty’’. Residents again said that they were generally satisfied with the range of activities on offer though there were a number of comments that there should be more outings. The Registered Provider said that there has been a recent outing, that residents when asked were not keen to have more outings and that residents families took residents out as well. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 15 The inspector saw a quiz activity in the afternoon of the inspection. Residents said they could go out if they wished and are able to and attend clubs - a resident was seen to go out to get a newspaper, and staff can take residents out for a walk in the village if they want this. There was a comment that a resident would like to have regular communion in in the home. The Registered Provider said that residents are offered services to meet their religious needs on admission but that this comment would be followed up. Residents said that their visitors were made welcome by staff and this was supported by the visitor’s comments. There were some comments about the home getting another pet. The Registered Provider said this would be discussed with residents. A number of bedrooms had bird window tables fixed to them so that residents could enjoy watching the birds feed. One resident said this was a real pleasure. Residents said there were no rules, e.g. going to bed and getting up times, whether to stay in their rooms or go to the lounge etc, and staff respected this. Staff said that it was important that residents were able to keep their independence so they could still do things for themselves. This was confirmed by comments made by residents. There are no residents meetings to ensure that there is a forum to air views and preferences, put forward suggestions etc. The Registered Provider said residents are well able to put their views forward though agreed that issues picked up by the inspector could have been put forward in these meetings. The Registered Manager may wish to consider inviting residents representatives to the meetings to be able to effectively put forward residents views, subject to residents approval. Residents again said that they enjoyed the food and that there was a choice each day for all meals residents. There were a number of suggestions to have a greater range of homemade soups, that a cooked breakfast should be offered every day and that some salt should be added to meals to make them have greater flavour. The Registered Provider said that the range of soups offered was good though he would follow up these comments further. Food records showed there were a variety of vegetables offered. Residents said there is a fruit supply and the Registered Provider got a residents a piece of fruit when she asked for it. The food tasted was found to be of a very good standard with a three course meal offered with two fresh vegetables followed by a tasty rice pudding dessert. The inspector again recommended that Residents Meetings ate set up to ask residents their opinion of the food at their meetings. This gives them the Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 16 opportunity to comment and then management can change the menu accordingly if needed. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 17 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. Residents views are listened to and acted upon and they and their representatives can be confident their concerns will be properly attended to. The Complaints Procedure needs to be altered to make it easier to make a complaint. EVIDENCE: Residents and the relative spoken with thought that if there was a problem then they were confident the management would sort it out. The Deputy Manager said that there have been no complaints since the last inspection. A Complaints Book is not currently kept. This was recommended so as to be available when needed and to indicate that no complaints have been made, if this is so. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the lead Agency, the local Social Service Department, as per the National Minimum Standard. The Registered Provider said these issues would be followed up. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 18 The staff spoken with were not fully aware of the procedure regarding of which Agencies to contact if the in house arrangement failed. The Deputy Manager said this would be followed up and staff tested. It was also recommended that a short procedural statement be drawn up and displayed to help staff to follow the procedure and so be able to fully protect residents welfare if this situation happens. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 19 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents see facilities as homely and comfortable. EVIDENCE: ‘’It is so clean and tidy here. They clean your bedroom every day’’. ‘’I have never had a problem with the cleaning and there are no smells ever’’. Residents all said that they liked their bedrooms and they could bring in their own things. These were observed to be personalised and homely by the inspector, with personal items of residents furniture, pictures, photographs etc. The lounges were comfortable and furnished in a homely fashion. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 20 There is currently no signing to the environment to assist with residents with dementia, e.g. photos on doors to make them more recognisable, same colour doors for bathrooms, notice of time, day, weather in the lounge etc. Management are recommended to consider whether this would be of benefit to current residents. Odour control was of a good standard with no smells, which residents positively commented on. A lock to a bathroom was not working. The Registered Provider said the handyman was working on locks that day and fixing them as needed, to ensure residents privacy and dignity. Lighting levels did not appear bright enough for residents with sight difficulties. It is recommended that the management refer to Vista, the organisation that represents people with sight problems, to see what they recommend. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet residents needs. Recruitment procedures are in place to properly protect residents welfare. Staff training systems are in place to plan to equip staff to meet residents needs though more training on relevant issues needs to be carried out. EVIDENCE: Generally residents thought there were enough staff on duty to meet their needs. The staffing rota demonstrated that staffing was normally three care staff plus a manager in the morning until 3.30pm, which then reduced to two care staff until the one waking night staff came on duty, with an on call system. The rota inspected indicated two care staff for some morning shifts. The Registered Provider said this was not a true reflection as all management input had not been recorded and he said this would be done in the future. This is needed to evidence that sufficient staff are on duty. There was a discussion with the Registered Provider that only having two care staff on late afternoon/evening shifts may not be enough to fully meet Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 22 residents needs. He said this was not the case at present but said staff would increase if residents dependency needs increased. Care staff also carry out domestic duties. There is a cook seven days a week so residents nutritional needs are covered. Staff said that the management of the home provides training. Records seen by the inspector showed this as there is a Training Matrix, which includes moving and handling, health and safety, care planning, nutrition, constipation, incontinence, catheter care, diabetes, stroke care, wound care, leg ulcers and pressure sore care. There was also evidence of induction training for new staff - the recognised Skills for Care induction pack was being used according to a new staff member and this was also seen in a staff file. Specific training on other residents conditions – e.g., dementia, hearing impairment, parkinsons disease etc, is still needed and other issues need to be added to the Matrix – infection control, food hygiene and fire training. The Deputy Manager said this would be done. Staff said they were encouraged to undertake National Vocational Qualification level training and this was seen in staff files and on the induction checklist. Recruitment records were inspected with Criminal Records Bureau /Protection of Vulnerable Adults checks and written references in place to ensure that residents are fully protected from potentially unsuitable staff and have a proper check of competency etc. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 23 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): 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 management of the service responds to the needs of the residents, and and the requirements of the staff. A minority of systems do not fully protect the health and safety of residents and thesa are being addressed. EVIDENCE: Residents, the visitors and staff spoken to said that the home was well run and they could not think of many improvements that were needed, apart from more outings. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 24 ‘’Its very well organised here. If you ask for anything they are very accomodating’’. ‘’Management here are very professional. They get things done and running smoothly’’. ‘’Management will always listen to what you say and act on it’’. ‘’I think the family run everything really well’’. Staff said they are supervised and supported though no records to support this. It was recommended that supervision records show what issues have been discussed, as per the National Minimum Standard, e.g. care issues, performance issues, training etc to act as a reference to monitor performance of staff and help them develop. Staff Meetings have been held and were recorded as to the issues raised to ensure the home runs smoothly to increase the quality of life for residents. A Quality Assurance system was in place with completed surveys carried out for 2008. It is recommended that they be also given to other interested parties - e.g. GPs, Social Workers, District Nurses etc. The results need to be included in the Statement of Purpose so that this information is available to residents and their representatives. It was recommended that an Action Plan is also included showing how the home has dealt with any issues that arise from the survey so that residents quality of life is shown to be promoted. The Registered Provider said that they do not keep records of residents monies, as residents or their relatives deal these with. Fire Precautions: System testing was on the required monthly schedules for emergency lighting and weekly fire bell testing was also carried out. Fire drills are carried out on a regular basis of at least every three months. There was also a fire risk assessment on file, which helps to ensure that proper fire safety systems are in place to protect residents. A staff member was asked the fire procedure and was not fully aware of the whole procedure. The Deputy Manager said this would be followed up for all staff to ensure they were fully aware of the procedure to ensure residents are kept safe. Two fire doors were wedged open in the home, which does not fully protect residents in the event of fire. The Registered Provider said these issues would be followed up and by the next day fire closures had been put on these fire doors to ensure proper fire safety. There is a Health and Safety folder with Risk Assessments for safe working practices so residents can be protected from any potential dangers in the home. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 25 The hot water temperature was measured at a bathroom hand basin at 47.2c and from the bath at 45.3c, which is higher than the National Minimum Standard of 43c. An Immediate Requirements Notice was issued to direct that this be swiftly dealt with to protect residents from scalding. It was recommended that hot water temperatures are regularly tested and recorded so that it can be seen that systems are regularly checked and residents fully protected from scalding risks. Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 26 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 27 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 OP38 Regulation 13 Requirement Health and safety systems must be fully in place regarding fire safety and hot water temperatures so as to protect residents at all times. Timescale for action 17/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP14 Good Practice Recommendations Residents outings should be more frequent based on their preferences. It is recommended that regular residents meetings be held to ascertain views to enable input into planning the home’s services. A review of the home’s food is recommended to look at flavour in food, offering more variety of soups and offering a cooked breakfast each day. 3. OP15 Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 28 4. OP16 There needs to be a clear Complaints Procedure to ensure the complainant is given a choice as to how to complain and to the proper lead agency. Staff need to be aware of the full Safeguarding procedure to protect residents from abuse. The staff training programme needs to include all essential issues. 5. 6. OP18 OP30 Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Alexandra House DS0000049312.V368517.R01.S.doc Version 5.2 Page 30 - 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. 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