Care Home: Alpha House

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What the care home does well One resident who competed the homes internal satisfaction questionnaire wrote, `this is the best home I have ever lived in`. The homes domestic size and layout make it ideal for non-institutional small group living. We agree with the comments made by the manager in the homes AQAA that Alpha House is `very homely`. Furthermore, as the home is managed and run by only two members of staff, one of whom lives-in, the residents reap the benefits of being supported by a very small group of carers who are very familiar with their unique needs and preferences. Meals are also very well balanced and the home is particularly good at catering for the varying cultural tastes of the people who live there. One resident wrote, `both the staff are very good cooks`. What has improved since the last inspection? All the requirements made in the homes previous report have been met in full. New more person centred care plans have been introduced that set out in greater detail what each residents personal goals are and how the home intends to support them achieve them. The long-standing manager has recently achieved her Registered Managers Award (National Vocation Qualification - Level 4), to meet National Minimum training targets for residential home managers. Furthermore, both the homes manager and relatively new member of staff have now received first aid training. The homes equal opportunities policy has been amended and now contains procedures for dealing with racial harassment and abuse. With the full involvement and agreement of one resident and their professional representatives this individual now occupies a bedroom which better suits their needs because it has en-suite shower facilities. All items of food kept in the home were stored correctly in line with basic food and environmental hygiene standards. Up to date records of all the fire drills involving the residents and staff are now being appropriately maintained in accordance with good fire safety guidelines. Since the homes last inspection the main lounge has been repainted and supplied with two new leather sofas. Finally, a new shed for one resident to keep their gardening equipment in has been purchased, which the manager hopes will be in place by the end of the month. The new manager has also improved the homes arrangements for ascertaining the views of the people who use the service by introducing quarterly resident/staff meetings and residents satisfaction questionnaires. What the care home could do better: All the positive comments made above notwithstanding there remains a number of things the manager must do to ensure the people who use the service are well cared and kept safe: The homes damaged fax machine must be repaired and/or replaced. This will ensure the home is able to communicate effectively with external bodies such as the CSCI, care coordinators and its sister home (Mary`s).The damaged chest of drawers and the missing ensuite shower screen in the ground floor bedroom must be repaired and/or replaced. This will ensure the resident who occupies this room lives in a more comfortable and homely environment. The way in which the manager assesses health and safety issues in the home must be reviewed. Risks associated with residents smoking in their bedrooms and not having a working lock on the cupboard door where COSHH products are kept must be assessed as a matter of urgency. This will ensure so far as reasonable practicable the people who use the service are kept safe. CARE HOME ADULTS 18-65 Alpha House 28 Warlingham Road Thornton Heath Croydon Surrey CR7 7DE Lead Inspector Lee Willis Unannounced Inspection 8 September 2008 10:00 th Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 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 Alpha House DS0000025749.V365049.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 Adults 18-65. 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. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alpha House Address 28 Warlingham Road Thornton Heath Croydon Surrey CR7 7DE 020 8665 0092 NONE 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) Dr Edward Newton Osei Appah Mrs Helen Appah Ms Felicia Aseidua Appah Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 3 22nd May 2007 Date of last inspection Brief Description of the Service: Alpha House is a privately run residential care home that provides personal support and accommodation for up to three adults with a past or present experience of mental ill health. The homes registered manager, Felicia Appah who lives-in, has been in operational day-to-day control of the service for the past eight years. This small mid-terrace house is located in a quiet residential street in Thornton Heath and is within easy walking distance of a wide variety of local shops, cafes, pubs, a public lending library, and large park. The home is also very close to a main line train station and numerous bus routes with good links to Croydon and central London. This two-storey property comprises of three single occupancy bedrooms and a staff sleep-in room/living quarters. All three bedrooms have en-suite toilets and wash hand basin facilities. One bedroom has its own en-suite shower unit. There is a shared toilet and bath on the first floor. All the communal space is concentrated on the ground floor and comprises of a main lounge/dining area, a galley style kitchen, and patio garden at the rear. All the residents have been supplied with up dated versions of the homes Statement of purpose, guide and their terms and conditions of occupancy. The homes current scale of charges ranges from £400 to £500 per week. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Following this inspection we now rate Alpha House as a 2 star performing service. This marks an improvement on its previous rating of one star rating. We therefore now consider the people who live there to now be experiencing good quality outcomes. From all the available evidence we gathered during this key inspection it was clear the service now has significantly more strengths than areas of weakness. Furthermore, where areas for improvement have emerged in the recent past the service has both recognised and managed them well. We spent three hours at the home. During the visit we met the long-standing manager. Both the people who use the service had either stayed out over night with friends or were on holiday. We looked at records and documents, including the care plans for both the people who use the service. The remainder of this site visit was spent touring the premises. We received two ‘have your say’ comment cards about the home, which were completed by both the people who live at there. As part of the inspection process the manager also completed and returned an Annual Quality Assurance Assessment (AQAA) to tell us about this service, how it makes sure of good outcomes for the people using it, and any future developments that are being planned. What the service does well: One resident who competed the homes internal satisfaction questionnaire wrote, ‘this is the best home I have ever lived in’. The homes domestic size and layout make it ideal for non-institutional small group living. We agree with the comments made by the manager in the homes AQAA that Alpha House is ‘very homely’. Furthermore, as the home is managed and run by only two members of staff, one of whom lives-in, the residents reap the benefits of being supported by a very small group of carers who are very familiar with their unique needs and preferences. Meals are also very well balanced and the home is particularly good at catering for the varying cultural tastes of the people who live there. One resident wrote, ‘both the staff are very good cooks’. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All the positive comments made above notwithstanding there remains a number of things the manager must do to ensure the people who use the service are well cared and kept safe: The homes damaged fax machine must be repaired and/or replaced. This will ensure the home is able to communicate effectively with external bodies such as the CSCI, care coordinators and its sister home (Mary’s). Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 7 The damaged chest of drawers and the missing ensuite shower screen in the ground floor bedroom must be repaired and/or replaced. This will ensure the resident who occupies this room lives in a more comfortable and homely environment. The way in which the manager assesses health and safety issues in the home must be reviewed. Risks associated with residents smoking in their bedrooms and not having a working lock on the cupboard door where COSHH products are kept must be assessed as a matter of urgency. This will ensure so far as reasonable practicable the people who use the service are kept safe. 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. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: The manager told us the homes Statement of Purpose and Guide was last reviewed in December 2007 and up dated accordingly to reflect all the changes in provision, including the removable of the erroneous statement about the service being a ‘rest’ home. The manager confirmed that the service now has one vacancy following the departure of one resident in December 2007. The home has not received any new referrals in the past 9 months. The manager demonstrated a good understanding of the problems that could occur if she did not ensure a prospective new resident was compatible with the other residents who had both lived at Alpha House for sometime. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. Improvements made to the care plan format ensures these documents now reflect what is important to the individual, their capabilities, and what support they require to ensure their personal, social, and health cares needs and preferences are met. Arrangements for assessing, managing, and reviewing risks are in the main sufficiently robust to ensure the people who use the service are kept safe. This ensures people receive the person centred support that meets their needs and wishes. EVIDENCE: We looked at the care plans for the two people who live at the home. As required in the homes previous report the manager has introduced a new care plan format that is far more person centred and is a better working Document. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 11 Both care plans viewed set out in great detail how these individuals current personal, social, and health care needs were to be meet, what their food likes and dislikes were, their interests, and relationships. Both plans had been reviewed twice in the past year, and the residents, their care coordinators and the homes manager had been in attendance. Since the homes last inspection the manager has introduced joint residents and staff meetings, which are being held on a quarterly basis. These meetings have been well attended and show clear evidence that the people who use the service are actively encouraged to participate in the running of the home. Care plans contained a number of risk assessments that covered various aspects the residents lives, including accessing the kitchen and the wider community, having a bath/shower, and self-medicating. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. The number and variety of social, leisure and recreational activities the people who use the service have the opportunity to participate in has improved since the last inspection, although there remains scope to continue improving links with the local community. Dietary needs and preferences are well catered ensuring the people who use the service are provided with daily variation and choice. EVIDENCE: On arrival both the people who use the service were out, one person having stayed over night with a friend and the other being on holiday with a local social club. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 13 During a tour of the premises it was positively noted as recommended in the homes last report that the lounge contained a lot more information about local community events by way of local newspapers and leaflets. It was also positively noted that the rear garden had been put to better use to enable one resident to grow their own fruit and vegetables, which was one of the interests identified in their care plan. Entries made in residents daily diary notes showed that some progress had been made by the home to ensure that one person in particular who lives at Alpha House had far more opportunities to go out and attend a local social club and spent time tending the garden. We concur with the comments made by the manager that significant progress has been made to provide the people who use the service with more stimulating social lives, although further work is still required. As previously mentioned in this report it was positively noted that the home continues to actively support one resident to maintain good personal relations with their boyfriend who they often visit. The manager also told us they support one resident to visit their family on a regular basis. The manager told us both the residents have been offered keys to their bedrooms and the front door. During a tour of the kitchen all items of food, including those taken out of their original packaging, were correctly stored in the fridge in dated containers. The fridge also contained a wide selection of fresh vegetables and ingredients for cooking Caribbean style cuisine, including plantain and ackee. The manager told us she regularly cooks Caribbean style meals to meet the culturally specific tastes of one resident in particular. One resident who completed our survey wrote, ‘the staff are very good cooks’. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. Suitably robust arrangements are in place to ensure the people who use the service receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are continually recognised and met. Policies and procedures for handling medication are in the main sufficiently robust to keep the people who use the service safe, as well as promote their rights to choose to manage their own medication independently (so far as reasonably practicable). Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 15 EVIDENCE: The visitor’s book revealed that various health care professionals continue to see both the residents at regular intervals. During the inspection the care coordinator for one resident telephoned the manager to enquire about their clients health and welfare. In response to one resident changing physical needs and with the individuals consent they have moved to the vacant ground floor bedroom, which has its own ensuite shower facilities. The manager told us this individual prefers to have showers as they have found taking baths increasingly difficult recently. The homes accident book revealed that there had been no significant accidents or incidents involving the people who use the service since it was last inspected. Furthermore, none of the people who live at the home have been admitted to hospital in this period. No recording errors were noted on any of the medication administration records (MAR) sheets that were currently in use. These records accurately reflected current stocks of medication held in the home on behalf of the residents. It was positively noted that based on an appropriate assessment of risk residents who are willing and capable of retaining control of their own medication are actively encouraged and supported to do so by staff. This ensures the people who use the service are given every opportunity to develop their independent living skills in line with the homes stated aims and objectives. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. The homes arrangements for dealing with concerns and complaints ensure the residents and their representative’s feel their views are listened too and acted upon. The home has an open culture where the residents feel safe and supported to share any concerns in relation to their protection and safety. EVIDENCE: The homes complaints log revealed there had been two formal complaints made about Alpha House in the past year. We received the first complaint, which concerned hygiene and heating in the home. The matter was fully investigated by the homes manager, the outcome of which was inconclusive. However, appropriate action was nonetheless taken to replace a lot of the homes ‘old’ plates and a thorough check of the homes heating systems carried out. No further concerns have been raised about hygiene or heating in the home since the original complaint was resolved at the end of 2007. The second issue concerned the garden. The complaint was upheld after the manager conceded she accidentally uprooted some of the vegetables one resident had planted - incorrectly believing them to be weeds. The matter was resolved when the resident concerned was compensated for the loss of their crop and formally apologised too by the manager. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 17 Records of both the aforementioned complaints have been appropriately maintained by the manager and include detailed information about the nature and outcome of the subsequent investigations into these matters. The manager demonstrated a good understanding of what constituted abuse and was very clear which external agencies needed to be notified if she witnessed or suspected abuse in the home. The manager told us no allegations of abuse had been disclosed within the home in the past twelve months. Documentary evidence was produced on request to show that the manager and the homes only other member of staff who was relatively new had both attended recognising, preventing and reporting abuse training in 2008. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. The overall the interior layout and decoration of the home, including its soft furnishings, ensures the residents live in a relatively comfortable and noninstitutional environment. The homes arrangements for controlling infection are also sufficiently robust to ensure the residents live in a hygienically clean and offensive odour free environment. EVIDENCE: Since the homes previous inspection the lounge has been repainted and supplied with two new leather sofas. The manager told us all the rubbish in the rear garden would be removed as soon as the new shed was built. The manager showed us a receipt for the new shed which had been bought to store one residents gardening equipment in. The manager assured us the shed Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 19 would be in place by the end of the month (September 2008). Progress made to achieve this aim will be inspected at the homes next inspection. The manager told us the homes fax machine has not worked for sometime. During a tour of the ground floor bedroom a damaged chest of drawers and a missing shower screen were noted. Overall, this bedroom looked relatively comfortable and was very personalised with lots of family photographs, pictures, and ornaments hung on walls and on various shelves. The temperature of hot water emanating from the first floor bath was found to be a safe 40 degrees Celsius when tested at 12noon. During a tour of the premises it was noted the home remains clean and no offensive odours noted. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. People who use the service have safe and appropriate support as there are enough competent, qualified staff on duty at all times. People’s needs are also met because the manager and the only other member of staff get the right training, supervision and support they need to carry out their duties effectively. EVIDENCE: On arrival the homes manager was the only member of staff on duty. She told us that at least one member of staff was always on duty in the home during the day and at night. The duty roster for the week revealed the live-in manager normally works from 7.15am to 7.45pm four days a week when she also sleeps-in. Friday to Sunday is covered by the homes only other member of staff. The manager told us they each take it in turns to be ‘on call’ when the other is on duty. Agency staff cover annual leave, sickness, and other Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 21 absences. The manager told us current staffing levels are adequate to meet the resident’s needs. Documents were made available on request that showed all the appropriate recruitment checks had been carried out by the home in respect of its new member of staff, which included an up to date criminal records bureau and Protection of vulnerable adults checks, two written references, and proof of their identify. Documentary evidence was also produced by the manager to show this individual had received a thorough induction, which had covered safe working practices, their role and responsibilities, and the needs of the residents. The homes only permanent member of staff is enrolled on a National Vocational Qualification in care course (Level 2), which a letter of acceptance stated they should have completed by February 2009. Progress made to achieve this aim will be assessed at the homes next inspection. Certificates of attendance were made available on request to show that the manager and the relatively new member of staff had both recently received training (2008) in first aid, health and safety, moving and handling, safeguarding adults, and medication handling. Staff records showed the relevantly new member of staff had received two formal supervision sessions with the manager since starting in March 2008, in addition to regular daily contact and quarterly staff/residents meetings. Topics covered included, qualifications and training to be achieved by the individual and their keyworker responsibilities. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using arrange of evidence, including a visit to this service. Resident’s benefit from living in a home that is run by a suitably qualified manager. Recent improvements made to the homes quality assurance and selfmonitoring systems ensure all the people who have a major stake in how the service is run have far greater influence regarding its day-to-day operation and future development. Overall, the homes health and safety arrangements are relatively robust, but smoking and COSHH risk assessments need to be carried out to ensure the people who use the service are kept safe. Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 23 EVIDENCE: The homes longstanding manager was able to produce documentary evidence on request to show she has finally achieved her Registered manager’s award NVQ Level 4. The manager told us she receives a lot of support from the relatively new manager of Mary’s Home (sister home to Alpha) by way regular supervision sessions, monthly inspection visits, and daily telephone contact. Documentary evidence of the reports compiled by the manager of Mary’s home following her Regulation 26 visits to Alpha House were produced on request to show they continue to be carried out on a monthly basis in accordance with National Minimum Standards. The manager told us her relatively new line manager is very approachable and a good communicator. It was positively noted that the manager has introduced resident satisfaction surveys to ascertain their views about how their home is run. Overall responses to this internal questionnaire were extremely positive about the standard of care provided. As required in the homes previous report the manager has now created an equal opportunities and racial harassment policy. The manager told us both the residents’ smoke in their bedrooms, which the service permits. However, the fire safety risks associated with this activity have not been assessed. Furthermore, the lock on the COSHH cupboard in the kitchen is damaged. This must be repaired and the risks this posses the people who use the service assessed. The manager was able to produce a fire risk assessment for the building on request, which she had up dated in June 2008. Other fire records revealed the homes fire alarm system continues to be tested on a weekly basis and that fire drills are being carried out on a monthly basis. As required in the homes previous report appropriate records of these drills are now being maintained. Up to date Certificate of worthiness were made available on request to show that suitably qualified engineers had checked the homes gas installations, water heating systems (legionella), fire alarms and extinguishers, and portable electrical appliances in the past twelve months. Alpha House DS0000025749.V365049.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 Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 3 3 X 2 X Alpha House DS0000025749.V365049.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 16(2)(ii) Requirement The homes damaged fax machine must be repaired and/or replaced. This will ensure the home is able to communicate effectively with external bodies such as the CSCI, care coordinators and its sister home. The damaged chest of drawers and the missing ensuite shower screen in the ground floor bedroom must be repaired and/or replaced. This will ensure the resident who occupies this room lives in a more comfortable and homely environment. The way in which the home assesses health and safety issues in the home must be reviewed. Risks associated with residents smoking in their bedrooms and not having a working lock on the cupboard where COSHH products are kept must be assessed as a matter of urgency. This will ensure so far as reasonable practicable the people who use the service are kept safe. DS0000025749.V365049.R01.S.doc Timescale for action 15/09/08 2. YA26 16(2)(c) 01/10/08 3. YA42 13(4) 15/09/08 Alpha House Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alpha House DS0000025749.V365049.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 Alpha House DS0000025749.V365049.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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