Inspection on 12/04/05 for Alexander Lodge

This inspection was carried out on 12th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexander Lodge 12/11/08

Alexander Lodge 12/11/07

Alexander Lodge 07/06/07

Alexander Lodge 28/11/06

Alexander Lodge 03/08/06

Alexander Lodge 28/11/05

Alexander Lodge 11/10/04

Alexander Lodge 12/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Alexander Lodge 41 Skinners Lane Ashtead Surrey KT21 2NN Lead Inspector Mr P Benthom Announced 12 April 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Alexander Lodge Address 41 Skinners Lane, Ashtead, Surrey. KT21 2NN 01372 276052 01372 813293 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Izette Davis Mr Izette Davis CRH (PC) 16 Category(ies) of registration, with number Old age, not falling within any other category of places OP 16. Dementia - over 65 years of age (DE(E)) 4. Physical Disability over 65 years of age (PD(E)) 2. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Out of the sixteen (16) service users accommodated, four (4) may fall within the condition of DE (E). The age/age range of the persons to be accommodated will be: OVER 65 YEARS. Out of the sixteen (16) service users accommodated, two (2) may fall within the category of PD(E). Date of last inspection 11 October 2004 Brief Description of the Service: Alexander Lodge is a large detached house, situated close to the local amenities of Ashtead. The home provides accommodation and personal care for up to sixteen service users in the category of older people. The accommodation consists of twelve single rooms, two double rooms, a lounge with a conservatory, and appropriate laundry and kitchen facilities. A garden is situated to the rear of the home, and a small parking area is available at the front of the property. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home had a comprehensive statement of purpose, which accurately depicted the services provided by the home. The service plans in place were comprehensive and are reviewed on a regular basis to ensure that they accurately depict service users’ needs. The home provided a high level of individualised support to service users. What the service does well: What has improved since the last inspection? There is a commitment from the proprietor to offer as much opportunity as possible to staff to undertake appropriate training. As a consequence since the last inspection several staff have achieved NVQ Level 2 training and one member of staff has completed Level 3 training and is now undertaking Level 4 and the Registered Managers Award. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 9 The home had a comprehensive statement of purpose, which accurately depicted the services provided by the home. Service users were very complementary about the care they received and considered the home met their needs well. Potential service users are only admitted after either the manager completes a thorough assessment. Examples of the assessment process found in the care files sampled on the day of the inspection were found to be comprehensive. It was established that a full assessment is being carried out, before the prospective service user commences their trial stay. Where possible service users are actively involved in the assessment process and if they wish their relatives and/or carers views are also taken into account. However it was found that some risk assessments were incomplete. This was brought to the attention of the manager who addressed the issue on the day of the inspection. The manager was able to demonstrate that the home had the capacity to meet the assessed needs of older people requiring personal care as stated in the statement of purpose. These include the provision of adaptations and equipment such as assisted baths, passenger lift, hoists and wheelchairs that were observed to be in place during the inspection. Prospective service users are encouraged to visit the service to have a look around, have lunch and talk with existing service users. The service provides the potential service user a trial period of six weeks, however this period of time may be extended if requested. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Health, personal and social care needs are adequately met in this home. EVIDENCE: Service Users’ care plans are drawn up from the perspective of the Service User and showed their individual preferences, likes and dislikes. Each service user had a key worker assigned who would take responsibility for completing and updating their care plan. A company quality audit tool is in place to improve the standard of care plan format. New Service Users when admitted to the home are assessed accordingly. They are given the opportunity to stay overnight prior to their permanent admission. Evidence that Service Users’ optical, dental and chiropody needs are met and confirmed in the diary and other records. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 11 The records showed assessed medical needs were followed up properly and notes taken of the care given. There were facilities and procedures available for the safe reception, storage, disposal, administration and recording of medication and controlled drugs were managed in accordance with relevant pharmacy guidance and regulations. The Proprietor/Manager stated that medication is only administered by staff trained to do so and qualified to NVQ Level 2. Specimen signatures of all staff qualified to administer medication are to be found at the front of the medicine administration charts. Staff were observed to interact in a respectful manner with service users, particularly those with dementia. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The systems in place for full Service User participation indicated that Service Users views are both sought and acted upon. EVIDENCE: There was evidence of a comprehensive range of activities, which are based upon how Service Users were using their time prior to admission to the Home. At the time of the inspection an exercise class was being held. This is a regular event and was seen to be enjoyed by service users. There were no restrictions placed on visitors and those present at the time of the inspection were made welcome by management and staff. Whilst the home does not have a designated visitor’s area privacy during visits may be secured using service users’ rooms. The home had spacious indoor and outdoor communal areas; social events were held frequently in these areas and visitors were invited. The manager stated that it was policy not to manage service users personal finances. Relatives and representatives or external agents act in their interests. Access to personal records would be facilitated on request in accordance with the Data Protection Act 1998. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 13 The menu is operated on a four-week rota and is compiled in consultation with Service Users. Service Users all reported positively about the meals. They were consulted at the beginning of the day about what they would like to have from the menu. The menu on the day of inspection was found to be wholesome and nutritious. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 The home has a satisfactory complaints system that is made available to all Service Users and staff. EVIDENCE: The home has developed its complaints procedure to incorporate details of the Commission for Social Care Inspection. The homes policies and procedures include protection of vulnerable adults policy and a whistle blowing policy. Since the last inspection staff had accessed the training regarding vulnerable adults on 7/12/04. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of the environment within this home is good and provides Service Users with an attractive and homely place to live, however odour control in some parts of the building is poor. EVIDENCE: Some areas of the Home were found to be mal-odorous although clean on the day of the inspection. This issue was immediately brought to the attention of the manager. Also the two commodes identified in two of the ground floor bedrooms require immediate replacement on account of their worn and stained appearance. The premises were seen to be appropriate for service users’ lifestyles and needs and accessible to relevant community facilities and services. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 16 Spatial standards in all bedrooms were in compliance with the National Minimum Standards for Adults (18 – 65). All of the Service Users bedrooms were furnished and decorated to a reasonable standard and they contained numerous personal effects that recognised the personal needs and lifestyles of the occupant. This service has a large lounge and dining room that is appropriately furnished. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Service Users are supported by competent and trained staff who have good awareness of their needs. EVIDENCE: The home is staffed at previously agreed levels. There are two staff plus the proprietor/manager on duty during the day. At night there is one waking member of staff and one sleeping in. It was concluded that the current staffing levels are sufficient. It is the expectation of the Manager that 50 of the care staff will achieve NVQ Level 2 by the end of 2005. One senior member of staff has completed NVQ Level 3 training and has commenced Level 4 and the Registered Managers Award. There is low staff turnover in this Home and there are appropriate training opportunities in place for staff. Agency staff are not used and gaps in the rota are covered by existing staff members. There is currently one vacancy for a domestic assistant. There are arrangements to carry out Criminal Records Bureau checks and two written references are required for all staff. There was evidence that all staff had had some mandatory training for the year and that other appropriate training had been booked leading up until the middle of September 2005. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 The manager is supported by staff in providing clear and consistent leadership in the home with all staff illustrating an awareness of their roles and responsibilities EVIDENCE: The home’s manager/proprietor is experienced, and capable of running the home. He is studying for NVQ Level 4 and the Registered Managers Award. He is also in the process of becoming an Internal Verifier for the NVQ qualification. The management of the home was observed to be open and inclusive. There was a positive, friendly and relaxed atmosphere. Service Users spoken with stated that they are content with the service provided. Service Users were observed to be settled and happy in their environment. There is a genuine commitment by the proprietor to regular and updated Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 19 training for all staff. Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 2 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 Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 21 NO 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 OP7 Regulation 15(2)(b) Requirement It is required that the missing risk assessment is completed as soon as possible It is required that odour control on the ground floor is more effectively managed It is required that the worn and stained commodes are replaced immediately Timescale for action With immediate effect 12/04/05 With immediate effect 12/04/05 With immediate effect 12/04/05 2. OP26 23 (1)(p) 3. OP22 23(1)[c} 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 Good Practice Recommendations There are to be no recommendations from this inspection Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey. GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexander Lodge H58 H09 s13548 Alexander Lodge v212342 120405 Stage 4 ann.doc Version 1.20 Page 23 - 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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