Care Home: Alexian Brothers Care Centre

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What the care home does well People thinking about moving in were invited to visit and spend time with the residents. They provide written information about the home to anyone thinking about moving in. Staff were observed to treat residents with respect. We observed the relationships between staff and residents to be very good and the residents spoken to confirm this. Residents said "they are all very helpful" and "they are grand, excellent, nothing is too much trouble". Staff reported that the management team were "very supportive and very helpful".Residents said the food is "good, there is a variety", "I have everything I need and if I am not happy I can speak to the manager". What has improved since the last inspection? Care plans are much more detailed and include residents` preferences in relation to getting up and going to bed and their favourite meals. The daily notes have improved and there is more information recorded. They are signing copies of documents presented during the recruitment process to show that they have seen the originals. There have been some good improvements in the medication systems. Supervision is now being provided to staff. A monthly newsletter is being produced and distributed to residents advising them of events in the home and staff events, such as babies born and staff returning to work after maternity leave. What the care home could do better: There is still scope for improvement in care planning. Footrests should be used on wheelchairs to minimise the risks to residents. CARE HOMES FOR OLDER PEOPLE Alexian Brothers Care Centre 171 St Mary`s Road Moston Manchester M40 0BL Lead Inspector Sue Jennings Unannounced Inspection 1st September 2008 09:30a 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 Alexian Brothers Care Centre DS0000066876.V370769.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. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexian Brothers Care Centre Address 171 St Mary`s Road Moston Manchester M40 0BL 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) 0161 681 1929 0161 947 3609 The Hospital Management Trust Care Home 73 Category(ies) of Old age, not falling within any other category registration, with number (73) of places Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies 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: Old age, not falling within any other category Code OP. The maximum number of service users who can be accommodated is: 73. Date of last inspection 8th April 2008 Brief Description of the Service: The Alexian Brothers Care Centre is registered to provide accommodation for up to 73 older people. The home is owned by The Alexian Brothers, Province of the Sacred Heart and the Hospital Management Trust (HMT) have been registered with the Commission for Social Care Inspection (CSCI) to assume full management responsibility for the Care Centre. The home is located in the residential area of Moston, in the north of the city centre of Manchester. Public transport links into Manchester City centre are within easy walking distance. There are ample parking facilities at the front of the building. The home is a three storey, purpose-built building set in its own spacious grounds. Accommodation for the residents is provided on three floors and is accessible to residents who use a wheelchair. All bedrooms are single and 48 are fitted with en-suite facilities. A variety of communal areas are available for residents, including a chapel with daily services. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 5 The home is divided into three units. There are two nursing units and one unit providing personal care only. The residents have a choice of lounges and dining rooms as the home provides several alternatives. The furnishings and décor throughout the home were found to be of a high standard. The residential unit provides a kitchen for residents and relatives/friends to make drinks or snacks at any time. Each unit provides a smoking room. The home has ample, well-maintained grounds. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 6 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. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 8.5 hours on Monday 1st and Tuesday 2nd September 2008. During the course of the site visit time was spent talking to the manager, the cook, three of the day staff and eight of the residents to find out their views of the home. Time was spent examining records, documents, residents’ files and staff recruitment records. Before the inspection, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we see the service. Fees for accommodation range from £375-00 to £480-00. There is an additional top-up fee. There are additional charges for physiotherapy, hairdressing, newspapers and toiletries. What the service does well: People thinking about moving in were invited to visit and spend time with the residents. They provide written information about the home to anyone thinking about moving in. Staff were observed to treat residents with respect. We observed the relationships between staff and residents to be very good and the residents spoken to confirm this. Residents said “they are all very helpful” and “they are grand, excellent, nothing is too much trouble”. Staff reported that the management team were “very supportive and very helpful”. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 7 Residents said the food is “good, there is a variety”, “I have everything I need and if I am not happy I can speak to the manager”. What has improved since the last inspection? What they could do better: 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. Alexian Brothers Care Centre DS0000066876.V370769.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 Alexian Brothers Care Centre DS0000066876.V370769.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Detailed information about the home is made available in various formats and people’s needs were assessed before they move in. EVIDENCE: There was an information pack provided to prospective residents that gave enough information for people to make an informed decision about moving in. The manager or deputy manager visited the person in their own home or in hospital to carry out a pre-admission assessment. Where possible, a care manager’s assessment was obtained. A care plan was written using the information gathered during these assessments. One relative said “I used to do some work close by and thought what a nice place it was” and “the religious aspect is important to us”. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 10 One resident said “I was told about it by my clergyman who has visited here many times”. As stated in the last report, people were able to visit the home before making a decision to move in. Where this was not possible, families were invited to visit on their behalf. The information was available in large print and would be translated into other languages if the need arose. The home does not provide intermediate care. Alexian Brothers Care Centre DS0000066876.V370769.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans addressed the health, personal and social care needs of individuals. EVIDENCE: We saw a sample of care plans for four people. Care plans were easy to use and were filed in a systematic order. We saw a good improvement since the last inspection and it was clear that they continued to work hard to improve the care planning systems. We saw some areas where minor improvements were needed. For example, information was in the care plans but not where you would expect to find it making it difficult to identify the person’s needs without reading through the whole plan. A recommendation is made that the written care plan is more regularly updated and information relevant to a particular need is kept together for easy access. Where residents do not use footrests on wheelchairs, a risk assessment should be included in the care plan. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 12 It was clear that staff were meeting residents’ needs. We saw staff approach residents with respect. Residents and relatives spoken to were complimentary about the care staff and the care their relative received at the home. They told us “the care is second to none” and “I go home with an easy mind because I know they are looking after her it has been very difficult for me to have her away from me but I am very happy with the home”. A friend or relative told us “my relative said they have never felt as well as they do now” and “they tell me everything if she has an infection or has to see the doctor, yes I am very lucky to have got a place here I go home very happy, very happy”, they also said “the staff are fabulous and not just with my relative, I see it with them all they are so kind”. One friend or relative told us “I come every day and the staff welcome me; I can make a cup of tea and stay as long as I want”. Another told us “I am very glad she is here” and he was content that “when I am not at the home my relative is being well looked after.” One relative told us “the staff look after my relative very well and from what I have seen, they look after all the residents well”. Another told us “the home runs smoothly and can’t fault it.” One friend or relative told us “it was not very good but things seem to be getting better, some of the staff are lovely”. Another said “Very happy with the home” and “you can have a drink and a biscuit whenever you want.” We saw one member of care staff introduce herself to a new resident. They explained who they were and what their role was. This was good practice. Residents told us “they are very good to us” and “they are grand, very attentive” another said “the staff are excellent, I can’t fault them.” We saw that regular health monitoring takes place and that care plans were being reviewed regularly. All residents were registered with a local GP and, where possible, residents had retained their own GP. Records of visits from other healthcare professionals were held in each resident’s file. During the inspection the pharmacist inspector looked at how well medicines were handled to make sure that residents were being given their medicines properly. All medicines were stored and disposed of properly, including controlled drugs. The records showed that medicines were being given as prescribed and that most medicines could be tracked and accounted for. When the stocks of medicines held in the home were compared with the records for those medicines, we saw that medicines had been given properly. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 13 The records clearly showed when medicine doses had been changed or when the doctor had stopped the treatment. The records also contained enough detail to make sure that residents were given consistent treatment, especially when a resident could not express their views clearly. Some people chose to look after some of their own medicines and the staff helped them to do this safely. New systems had been introduced to make sure medicines did not run out and the residents’ treatment was continuous. The new systems also made sure that any newly prescribed medicines were obtained quickly so that there was no delay in starting treatment. The manager had introduced a wide-ranging system of auditing the medicines to help make sure that they were given safely. The audits were very thorough and enabled any problems to be found quickly and solved. Overall, we found that medicines were handled well and residents were given their medicines safely. Alexian Brothers Care Centre DS0000066876.V370769.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 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The home offers a wide range of recreational activities. A well-planned and varied diet is provided and residents’ choice is very well catered for. EVIDENCE: Staff were observed welcoming visitors into the home. There was an open visiting policy and residents were able to see visitors in one of the lounges or in the privacy of their own rooms if preferred. One resident told us their visitors were always made to feel welcome and can visit at any time. Other residents said that they were able to have friends and family visit when they liked. We saw that one resident had a telephone in their bedroom so that they could keep in touch with relatives and friends. They told us “the phone was a necessity, I like to keep in touch with my family and friends”. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 15 They told us that residents were able to choose an alternative to the set menu if they did not like the menu choice for the day. Residents told us “the food is good” and “the meals are usually very good, very tasty”. One resident told us “If I did not like the meal on the day I am sure they would make me something else but it has never happened to me yet, the food is very good”. One resident told us that the “home is fine”, that “the food is nice enough and there is lot of it” and “the meals are very nice; you know, plain meat and veg.” We saw the home’s chapel. This was a calm and peaceful area where residents, staff and people from the community could sit and pray or spend some quiet time alone. As stated in the previous report, residents are able to maintain their religious beliefs and attend mass in the chapel. Those residents unable to attend the daily mass can watch the service in their bedroom via a television channel. One relative told us “the religious aspect was very important for us”. Another resident told us “I like to watch the service on TV, I can’t get to the church”. A relative told us “the brothers sing to my relative and she loves it”. The manager told us that admission to the home is not restricted to Roman Catholics. The manager told us that arrangements would be made to support residents from various religious backgrounds as and when required. Routines are very flexible and residents can make choices in all areas of their life. We saw staff helping residents who needed support during mealtimes, including those who have difficulty swallowing or chewing. Mealtimes are flexible and relaxed, staff are patient and helpful, and allow people the time they needed to finish their meal comfortably. We saw that the menus were varied and balanced and cater for the varying dietary needs of residents. The dining areas were bright and inviting. One resident told us “I like to walk around as much as possible to keep going, they are very good to us.” Another told us “they try to give you what you like they do very well” and “there is always something going on here”. Residents enjoyed a full and active lifestyle with a number of different in-house recreational activities on offer. There is an activities organiser and a weekly programme of activities was displayed in the entrance area of the sun lounge on the residential unit. An activities programme was in place that included outings to local areas of interest, art classes and discussion groups, board games, visiting entertainers, video shows, planting seeds and knitting. We saw photographs of recent events, e.g., a St George’s day party. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 16 Residents told us they were able to participate as they chose in any activities. Staff respect any decision made by residents in relation to participation of activities. The manager has started to write a monthly newsletter. This includes information about staff leaving to have babies and those returning from maternity leave. This keeps the residents up to date with what is going on in the home. There was a hairdressing salon and this gave the impression of being in a hairdressing salon in the community. This was a well-used facility and residents were able to sit and chat whilst having their hair cut and set. The home has a large library for residents to use. This was a quiet room that was well stocked with a wide variety of books from fiction to psychology. Alexian Brothers Care Centre DS0000066876.V370769.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There was a complaints procedure and policies, and procedures were in place to make sure residents were protected from harm. EVIDENCE: We saw that there was a written complaint procedure and all complaints received were recorded. This record included details of the complaint, the investigation and the outcome. We saw copies of the complaints procedure on the back of residents’ bedroom doors. Staff told us that they would raise any concerns they have with the manager. Residents told us that if they had a complaint they would “speak to the manager”. A friend or relative told us “I have no complaints but I would speak to the manager or one of the seniors”. Another resident told us “I have never complained but would do if I was not happy” The complaints policy and procedure was displayed in the home and information about how to make a complaint was included in the service user guide. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 18 There was a copy of the Manchester Multi-Agency Policy on the Protection of Vulnerable Adults available for staff to reference. There had been no adult protection referrals made. There is an ongoing staff training programme that includes safeguarding adults. Staff were aware of the action to be taken in the event of an allegation of abuse being made. There was evidence to show that staff received training in safeguarding adults so that they were able to recognise abuse and report it. Alexian Brothers Care Centre DS0000066876.V370769.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): Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The premises are safe and the home’s environment, including the standard of hygiene, was well maintained both internally and externally. EVIDENCE: We saw a sample of bedrooms and residents told us “I like my room I spend a lot of time in here”, “the place is very clean”, “it is always very clean and tidy; they work very hard” and “I am really happy here”. Bedrooms have an ensuite toilet and washbasin. We saw that bedrooms had views across the gardens and the main road. They were all bright and airy and furniture was of a good standard. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 20 Residents were seen relaxing after lunch in the small lounges either reading or watching television. There are small kitchens on each floor so that residents and/or their visitors can make a drink. Residents spoken to said that it was like living in their own home and they were able to come and go as they please. Another resident told us that their room was “clean and tidy and it is always like that”. There was evidence that residents had brought some personal belongings with them. All rooms seen were found to be clean and tidy and well decorated and those residents spoken to said that they were very happy with their rooms. There were enough domestic staff to keep the home clean and we noted that there were no unpleasant odours during the tour of the home. Sanitising hand gel dispensers were seen throughout the home to minimise the risks of crossinfection. The dining rooms were bright and airy with a relaxed comfortable atmosphere. Aids and adaptations were provided to assist in moving residents safely. These included manual hoists and adapted baths. We saw that staff had received manual handling training to enable them to use the equipment safely and safeguard residents. The home has a large chapel and has daily services that can be viewed on a special television channel and this meets the specialist cultural and religious needs of the residents. There is a pleasant seating area in the foyer and a bright and airy garden room; residents were seen to use these areas. There are large well-maintained gardens with a number of seating areas where residents can sit out in the warm weather. Alexian Brothers Care Centre DS0000066876.V370769.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The numbers and skill mix of staff was sufficient to meet the needs of the residents accommodated and staff had access to a wide range of training. EVIDENCE: A sample of staff files was examined these were well maintained and contained all the necessary checks. We saw that Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks had been obtained to make sure that staff are safe to work with the residents. We saw that staff files contained photocopied documents, for example, passports, utility bills and certificates. We saw that they had begun to sign the photocopies to show that the original documents had been seen. We saw that there were enough staff on duty to meet residents’ needs. Staff spoken to said that they had access to training. The manager told us that regular staff supervision had started and all staff completed an induction period. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 22 We saw that staff were given a copy of their job description detailing their roles and responsibilities. Training needs were identified during supervision and the home provided ongoing refresher training. Staff have the opportunity to complete the NVQ in care. They told us that 22 care staff had achieved NVQ level II and that two were working towards the qualification. They told us that four of the staff had achieved NVQ level III and that three were working towards this qualification and that one member of staff has achieved NVQ level IV. We saw that staff were caring and approached residents in a polite and respectful manner. Residents told us that staff were “kind and caring”, “very helpful”, “lovely”, “they are grand excellent” and “quite friendly”. Alexian Brothers Care Centre DS0000066876.V370769.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 and 38 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 home that is safe, well managed and run in their best interests. EVIDENCE: The manager has considerable knowledge and experience of running a care service for older people. They had a good understanding of the conditions and illnesses that are associated with old age and were able to address such issues quickly, benefiting the residents. The manager has submitted an application to be registered with the commission. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 24 The manager has showed a good understanding of the areas of weakness and there is a good capacity for the service to improve. They told us that they have a quality assurance questionnaire that is sent out on an annual basis to residents, relatives and staff. The feedback from this is used to improve the service. They told us there was an open door policy and residents and staff had access to senior staff at all times. Staff spoken to said that the management was always ready to listen to concerns and answer questions. Feedback from care staff was positive about the support they received from the home. Comments included “this manager has turned the home around” and “staff morale has improved” and “it is the same with all staff not just heads of department the manager never turns anyone away.” As stated in the last report, the home’s administrator has responsibility for residents’ monies. They had computerised records that were password protected and receipts were kept for any purchases made on the residents’ behalf. They told us that supervision had started for all staff and that this will be provided on a regular basis. The home’s certificates of registration and public liability insurance had been displayed in the entrance hall. These were accurate and up to date. Fire equipment had been regularly maintained and staff had received fire awareness training. Fire alarm systems are tested on a weekly basis by staff in the home and annually by the local Fire Officer. All records were held securely in locked cabinets in compliance with the Data Protection Act 1998. This made sure that personal information about residents remained confidential. Policies and procedures were in place with regard to managing residents’ finances. Records kept at the home indicate that the financial interest of the residents is safeguarded. They have a quality assurance monitoring system in place and the feedback is analysed and used to improve the service. They continue to let us know about things that have happened since our last key inspection and they have shown that they have managed issues well. They work well with us and have shown us that their service provides good outcomes for the people who use it. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations It is recommended that the written care plan is more regularly updated and information relevant to a particular need is kept together for easy access. Where a resident does not use footrests, a risk assessment should be in place in the care plan. Alexian Brothers Care Centre DS0000066876.V370769.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Alexian Brothers Care Centre DS0000066876.V370769.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. 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