Inspection on 12/11/07 for Alexander Lodge

This inspection was carried out on 12th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 07/06/07

Alexander Lodge 28/11/06

Alexander Lodge 03/08/06

Alexander Lodge 28/11/05

Alexander Lodge 12/04/05

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 Alexander Lodge 41 Skinners Lane Ashtead Surrey KT21 2NN Lead Inspector Pat Collins Unannounced Inspection 12th November 2007 10:35 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 Alexander Lodge DS0000013548.V352103.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. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander Lodge Address Alexander Lodge 41 Skinners Lane Ashtead Surrey KT21 2NN 01372 276052 01372 813293 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) Mr Izette Aeon Davis Mrs. Desline May Davis Mr Izette Aeon Davis Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (2) Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Out of the 16 (sixteen) service users accommodated, 4 (four) 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 16 (sixteen) service users accommodated, 2 (two) may fall within the category of PD (E) 6th August 2007 Date of last inspection Brief Description of the Service: Alexander Lodge is a care home registered to provide accommodation and personal care for up to 16 older people. This includes a specified number of places for older people with dementia and/or physical disabilities. Situated in a quiet residential area, the home is near to the shops and public amenities of Ashtead village and not far from Epsom town. The building is a three storey, large detached house that is domestic in scale and character. There is a small garden at the rear of the property and car parking facilities for three or four vehicles at the front. Bedroom accommodation is arranged on all three floors, accessible by passenger lift and stairs. Two shared bedrooms have recently been converted to provide all single occupancy bedroom accommodation at the home. This change has reduced maximum occupancy levels to fifteen though the home is currently registered for sixteen. Communal rooms are on the ground floor. These comprise of a dining room, a comfortable combined lounge and conservatory, utility room and kitchen. Fee charges range between £450.00 and £550.00 per week. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit forms part of the key inspection process using the ‘Inspecting for Better Lives’ (IBL) methodology. It commenced at 10:35 and finished at 17.30 and was carried out by one regulation inspector. The home’s manager, who is one of the home’s two owners, was present and is referred to as ‘the manager’ in the report. Judgements about standards of care and how well the home is meeting the national minimum standards for older people are made on the basis of the cumulative assessment, knowledge and experience of the home since its key inspection in June 2007. Also taking into account the findings of an unannounced inspection by two inspectors on 6th August 2007. The purpose of that inspection was to follow up action taken for compliance with a breach of regulations, as detailed in a statutory requirement notice served on the homeowners. The report of that inspection is available to the public by request to the Commission for Social Care Inspection (CSCI). The required Annual Quality Assurance Assessment (AQAA) completed by the manager was used to inform the inspection process. A partial tour of the building was carried out and records, policies and procedures sampled. Other information was obtained through discussions with the manager, two care staff, the cook, a visitor and a fire officer. Discussion took place also with three people using services, hereafter referred to as ‘residents’ in the report, in accordance with their expressed preference. Feedback from some residents consulted was limited owing to communication difficulties. Observation of their body language, appearance and records however, together with information provided by staff, indicated a sense of their well - being. The content of survey questionnaires from two relatives and two professionals also informed judgements about the home. The inspector wishes to thank all who contributed information; also the residents, manager and staff for their time, hospitality and assistance throughout the inspection visit. What the service does well: Care and attention were paid to residents’ personal appearance at the time of the visit. Staff were attentive to their needs and wishes and arrangements for personal care respected residents’ privacy and dignity. Observations concluded the day-to-day operation of the home promotes residents’ choice, independence and control over their lives, within individual levels of capacity. Interaction between staff and residents was appropriately informal, frequent and friendly. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 6 The inspector had contact with all residents and in depth conversations with three who were complimentary about staff and satisfied with the home’s operation and management. One resident commented, “I am happy to be living in such a nice place, the staff are lovely”, another said, “The staff are all very good and caring”. All three stated they enjoyed their lunch on the day of the visit and were overall satisfied with meals. A visitor described her delight at the significant improvement noted in the resident she was visiting in the short time since her admission. Comments from relatives in survey questionnaires returned, included, “They are very caring, don’t see residents as a business, they genuinely care for their wellbeing” and “The home is friendly and caring”. A General Practitioner commented, “Staff show respect and knowledge of residents’ needs”. Another professional said, “I always feel reassured that residents receive a good standard of care. The manager and staff have a good relationship with residents and take time to discuss their needs and preferences. Residents appear happy and content and staff have a good understanding of their individual needs”. Admission assessment procedures ensure admissions are agreed on the basis that the needs of prospective residents can be met. The quality of information produced about the home enables prospective residents and/or their relatives or representatives to make informed choices about the home’s suitability. Equality and diversity policies are put into practice in admission procedures, staff recruitment and training. It was good to note orientating visual information in the environment, in keeping with the home’s stated purpose. What has improved since the last inspection? Requirements from the last inspection had been met. Improvements include an ongoing maintenance and redecoration programme that has enhanced the appearance and comfort of the environment. This includes conversion of shared bedroom accommodation providing all single occupancy bedrooms and two additional en suite toilets. Some worn furniture, vanity units in bedrooms and further carpets have been replaced. A small ramp has been added to the front entrance. The home was clean and fresh at the time of the visit. The staff team has increased in size, improving the safety of shift patterns and reducing the need for the manager and staff to work excessive hours. Records confirmed new staff had received a formal induction and staff training opportunities had increased. The manager and some staff had recently received fire safety and safeguarding adults training. They had also enrolled on a distance learning infection control course and basic food hygiene training was booked. The manager had a confirmed place on a training workshop entitled, ‘safer food, better business’ and had completed a dementia care course. Record keeping practice has improved in some areas. Specifically, maintenance of accurate staff rotas, for regular monitoring of hot water temperatures and relating to the management of medication. Though at a very early stage, it was positive to note the intention to implement an improved, person-centred care planning system. A more comprehensive preAlexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 7 admission assessment tool was now used. It was noted that risk assessments contained actions to minimise and reduce risk. The home’s complaints procedure had been reviewed and complaint forms implemented. What they could do better: The manager agreed to give priority to finalising a draft revised fire evacuation procedure and ensure staff are all trained in this new procedure. This revision was required following a fire safety audit in September undertaken by the Surrey Fire & Rescue Service in response to a change in fire safety law. Other requirements are to be addressed in the home’s fire risk assessment and in a time-specific corrective action plan that the manager stated he was working on. A fire safety specialist had carried out a fire risk assessment, however some inaccuracies in his report require correction and a further visit is being arranged. Though the manager has relevant professional qualifications and experience and has recently updated his knowledge through further training, the management standard is not fully met. This is because the manager does not possess a relevant management qualification. It was positive to note his intention to undertake the registered managers award qualification (RMA). The manager should explore enrolling on a combined course leading to the National Vocational Qualification (NVQ) Level 4 in management and the RMA. There is a need to apply for variation of the home’s registration, reflecting the reduced number of places. The statement of purpose, the book that says who the home is for, also the service users guide, the book that says how it works, both need updating to also reflect this change. Nutritional assessments should be carried out for all new residents and admission weights recorded. Weights should be regularly monitored for all residents and suitable weighing scales purchased. The scope of residents’ risk assessments needs to be extended, using recognised tools. These should cover moving and handling, falls, pressure sore prevention and access to toiletries in bedrooms. Whilst noting risk assessments now include risk reduction actions, ideally these should then be addressed by detailed care plans. Details specific to this comment can be found in the Personal and Healthcare section of this report. Care plans and care notes must be holistic, demonstrating how social and diversity needs are addressed and the process inclusive of residents. Staff require training that will enable them to competently implement one of the risk management actions for a resident who has an insulin dependent diabetic condition. A recent photograph was not on the two care records examined, as required. The staff recruitment application form should be amended to require a full employment history for all prospective employees. A record of the date staff commence employment must be maintained. The manager must adhere to the policy for recording, storage and disposal of Criminal Records Bureau (CRB) Disclosures for staff. Also ensure self-employed people who are Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 8 contracted to provide a service for residents, and are with them unsupervised, have had relevant checks through the CRB. Areas of discussion with the manager included the need to review staff recruitment practices. Staff recruited since the last key inspection did not have letters of appointment on their files. It was not evidenced that all staff had been issued with contracts of employment. The need to ensure the staff induction covers the common induction standards was discussed. Quality assurance systems could be further developed, incorporating regular quality audits. The home uses questionnaires to gain residents and relatives views. A clear procedure needs to be in place for sharing this feedback with residents, also any proposed action for improvement or change. 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. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 9 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 Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 10 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): Standards: 1, 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have access to written information enabling an informed choice about the home’s suitability. New residents are admitted on the basis of a full needs assessment carried out prior to admission and receipt of all relevant information, to be assured needs can be met. Service provision does not include intermediate care. EVIDENCE: The statement of purpose, which is a book that tells people who the home is for, was displayed prominently in the home. The service users guide, a book that tells people how the home works, was also displayed and residents have personal copies in their rooms. Both contain relevant information. A minor amendment is necessary to these documents to reflect recent changes to bedroom accommodation and en suite facilities. The manager agreed to amend the same. He advised that prospective residents and/or their relatives, if they are unable to visit themselves, are offered opportunity to look at these documents when they view the home. These enable an informed choice about Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 11 the home’s suitability. The service users guide refers to the admission criteria affording equal opportunities for all who apply. It states, “We accept applications from people of all walks of life with different needs, who enjoy opportunity to share and celebrate richness of diversity of the experience. All are made aware of the home’s diversity and anti-discriminatory policies. There is commitment to ensuring no one is excluded on grounds of ethnicity, religion or culture”. Residents’ rights and quality of life values are clearly set out in both documents and admission procedures operate in accordance with these principles. The home’s admission criteria is in accordance with the home’s registration categories and service provision does not include intermediate care. The manager carries out a comprehensive needs assessment for all prospective residents prior to admission, ensuring copies of community care assessments are obtained where available. Medical information is also sought to ensure needs can be met. Though occupancy levels are currently low, there being only seven residents at the time of the visit, the manager was clear he will not accept referrals unless he is satisfied that the placement is appropriate. The manager advised that on occasions he has had to decline referrals after carrying out his own assessment on the grounds of high levels of dependency bordering on the need for 24 hours nursing care. There have been four admissions since the home’s last key inspection. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 12 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): Standards: 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Basic care plans are available to guide staff in meeting residents’ needs. These need to be further developed, also residents’ risk assessments, using recognised tools. This process needs to be more inclusive and involve residents or as appropriate, a representative. The management of medication has improved. The home must have equipment to enable weights to be monitored and staff training provided to enable them to fully follow a resident’s risk reduction plan. EVIDENCE: All residents are registered with a local GP practice. Feedback received from two professionals confirmed their observations that staff show respect for residents and knowledge of their needs. All three residents consulted during the visit, expressed satisfaction with their care. Observations confirmed staff ensured attention given to residents’ personal appearance. Staff were attentive to residents’ needs, interaction between them and residents being informal, frequent and friendly. Personal support and care practices respect residents’ privacy and dignity. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 13 The home does not provide nursing care and is supported by the local district nursing service. District nurses visit daily to meet the needs of one resident and provide regular treatment for two others. There is an infection control procedure. The manager has received the Essential Steps Tools for reducing healthcare associated infections from the Department of Health, though this has not yet been implemented. He and a number of staff have recently enrolled on a distance learning infection control training course. In all toilets and bathrooms liquid soap and paper hand towels were supplied and protective gloves and aprons were available in the home. The washing machine has a sluice cycle to enable the hygienic management of soiled and infected linen. The home was stated to have a contract for a yellow bag clinical collection service for disposal of incontinence pads. The manager confirmed input from an incontinence advisor to assess needs and arrange free access to NHS incontinence aids. A risk management plan was in place for catheter care and measures for reducing risk. The service users guide states that each resident has a care plan and they will be consulted about this, also friends and family. Observation made of two care plans did not evidence residents’ involvement in this process however. There was not a current photograph either attached to these care plans or on medication records. The service users guide states that care plans are regularly checked and reviewed in three stages, at the end of the trial placement period, thereafter monthly and annually. Monthly reviews were evidenced to take place. Three residents whose places are funded by care management and two who are self-funding were confirmed to have had their care plans reviewed in the last twelve months. Information gathered during pre-admission assessments is used to form the basis of individual care plans. The new pre-admission assessment was noted to be more comprehensive than the former assessment format. Risks were identified, though use of risk assessment tools not evidenced. Risk reduction action plans included control measures for minimising risk. Whilst some improvement was evident in response to requirements and discussions at the last key inspection, risk assessment and care plans need to be yet further improved. The use of risk assessment tools for moving and handling, pressure sore prevention and falls is strongly advised. A nutritional assessment should be carried out on admission and record of admission weights recorded and weights monitored. The home needs to have suitable weighing scales for this purpose. Record keeping specific to care should be less fragmented. For example, an assessment stated to have been carried out for a resident by a speech and language therapist, since admission, was not produced. For another resident who appeared unsteady walking with walking sticks, the professional assessment stated to have taken place since admission in respect of walking Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 14 aids was not on her file and not seen. Risk reduction action points are not an adequate substitute for care plans that need to be produced for specific areas of risk. For example one resident has swallowing problems, other risks distinct to two separate medical conditions and risk of falls. These need to be addressed in separate care plans. A resident who has insulin controlled diabetes needs to have an overarching care plan in place detailing the checks, treatment and responsibilities of all involved in his care. Also incorporating information currently recorded in risk reduction plans. It is acknowledged the latter describes indicators enabling staff to recognise an hypoglycaemic attack and action to take; part of the action plan however cannot be followed without further staff training, enabling blood glucose levels to be checked. The manager advised that some staff have been shown how to do this however this training needs to be formalised and recorded. The manager should also ensure, when planning the staff rota, that in his absence staff are competent to follow the risk reduction plan for this individual. This care plan needs to also incorporate information about food that is in the risk reduction plan and address foods that should be avoided. Other areas of discussion included the need for care plans to be holistic. Their current focus is on physical needs. The manager advised that the new care planning format is person centred and social care needs will be addressed. The home operates a group allocation system and the manager writes and updates all care plans. He said he intends to involve staff more in residents’ assessments. The manager or staff administer all medicines. It was stated that none of the residents have capacity to self-medicate. The home has a medication policy and staff responsible for medication administration had received Level 1 training from an external credible source. The manager must satisfy himself that the content of these 3 modules incorporates level 1 and 2 training which is the minimum required, in accordance with CSCI guidance. The storage, recording, administration and disposal of medication was satisfactory. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 15 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): Standards: 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users guide details the way social life in the home is organised. The activities programme gives prospective residents a clear idea of what is on offer. The home’s operation promotes residents’ choice, independence and control over their lives. Residents can maintain links with families and friends. The menu offers a choice of meals and appears balanced and varied. A holistic approach to care planning is needed and care notes must provide a record demonstrating how the home meets residents’ individual social, cultural, recreational and religious needs. EVIDENCE: Feedback from three residents and three relatives and observations during the visit confirmed the home’s atmosphere to be welcoming. Residents were noted to exercise control over where they spend their day, either in communal areas or in their bedrooms. It was good to see orientating visual cues around the home to prompt residents in finding their way round the building. Also other orientating information displayed, for example, details of the date, day, weather, topical news events, names of staff on duty and the day’s menu. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 16 The service users guide details provision for social stimulation. On the morning of the inspection a care assistant and volunteer were in the lounge with two residents. All were enjoying a game of scrabble. Residents and staff said they played card games, bingo, skittles and indoor bowls and sometimes enjoyed a selection of songs. The volunteer said he spends time at the home once a week. Whilst he referred to his Christian and missionary background, his purpose in visiting residents was not to meet spiritual and religious needs, though willing to discuss the same if residents wish to do so. He encourages residents’ to engage in socially stimulating activities. A programme of planned activities was displayed on the notice board in the central hall, between the dining room and lounge. This informs residents of planned activities. This is not, however, an accurate record of activities taking place as the programme is flexible, enabling residents’ choice. Observation of care plans and care notes sampled concluded their predominant focus on residents’ physical needs. A more holistic approach to care planning and to recording care notes is necessary in order to demonstrate residents’ social and diverse needs are also identified and met. The manager advised this is intended when the new care planning system is implemented. Though religious and other beliefs are identified in assessment information, with the exception of a statement saying a resident may use his bedroom for prayers and specifying a particular food this individual does not eat on religious grounds, records and care plans for other residents did not show how their religious beliefs were met. The manager confirmed a priest used to visit the home but had not done so for a while. Photographs were displayed of a resident enjoying a day out with staff to a local theme park. The manager advised that the same resident occasionally visits the village shops with staff, though records did not support this information. The use of community facilities needs to be recorded and further effort made to promote local community events, encouraging residents to go out. The manager stated that the majority of the residents were reluctant to go out with staff when offered opportunity. Family and friends are made welcome and there are no restrictions on visiting times. A cook works six days a week and confirmed she had recently updated her food hygiene certificate. On her day off, the other registered provider cooks the main meal. She is also responsible for menu planning and for purchasing food. The kitchen is domestic in style and was observed to be clean and hygienic. The Environmental Health Department inspected food hygiene in 2006 and requirements and recommendations from that inspection had been met. A four weekly menu is available in the dining room and the meal served on the day of inspection reflected this menu. The day’s menu was also clearly displayed on a white board outside the dining room. The manager advised that a dietician had looked at the menus since the last inspection and made no suggestions for change. Noting provision of semi – skimmed milk for all residents it was suggested that the dietician’s opinion be sought on whether whole milk would be more nutritional. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 17 The two –course lunch cooked from fresh produce was served in the dining room. The meal appeared appetising and was well presented. Residents able to express their views said they had enjoyed lunch and overall were satisfied with catering standards. Special dietary needs were met. A resident who was feeling unwell ate in her room. The cook willingly accommodated her request for food that was not on the menu. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 18 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): Standards: 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure has been revised and is accessible to residents and their representatives. The staff team has undertaken safeguarding adults refresher training since the last inspection. The home’s safeguarding procedure needs review. Staff recruitment procedures overall protect residents, however the manager must satisfy himself of the vetting credentials of self-employed people with unsupervised access to residents. EVIDENCE: The complaints procedure has been reviewed. It is accessible to residents and visitors on a notice board in the main corridor, together with complaints forms, which are a new development. The complaints records confirmed no formal complaints have been received by the home since the last inspection. The manager said that because the numbers of residents is small there is opportunity to talk with residents daily and visitors very regularly. This enables him to pick up on and respond to any dissatisfaction, however minor, thereby preventing concerns developing into complaints. The Commission for Social Care Inspection (CSCI) has not received any complaints about the home since the last key inspection. Additionally no referrals have been made under safeguarding adults procedures. The manager stated that the home would follow the Surrey safeguarding adults procedures in the event of an allegation or suspicion of abuse or Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 19 neglect. An up to date copy of this procedure was available for reference in the office. The need to review and develop the home’s safeguarding adults procedure was identified. This needs to include clear instructions for line management reporting of this type of incident; also clarify responsibilities for safeguarding adults referrals. There is a whistle-blowing procedure. The two induction records for new staff confirmed they had been informed of the safeguarding adults and whistle blowing procedures. Since the last inspection eight staff, including the manager, have received safeguarding adults training from an external trainer. The manager stated he attended a Surrey County Council safeguarding adults training event in 2003 and in 2005 received this training again from an independent trainer. Observations confirmed new staff employed since the last key inspection, also the volunteer, had Criminal Records Bureau (CRB) Disclosures. Checks had been undertaken prior to their working at the home, to ensure they were not on the national list of people unsuitable to work with vulnerable adults. The need to verify that self- employed people with unsupervised access to residents also have had these checks was discussed with the manager. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 20 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): Standards: 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An upgrading, redecoration and refurbishment programme is ongoing. This is gradually improving the environment and raising standards. A renewal programme for replacing some worn furniture, bedroom vanity units and carpets is in progress. It was good to note bedroom accommodation is now all single occupancy and two additional en-suite toilets. Communal areas are comfortable, all areas are clean and odour is well controlled. EVIDENCE: Requirements made at the time of the last inspection have been met. The appearance of a bathroom had been enhanced and safety and comfort of the bath hoist improved. A tour of the premises included observation of all communal areas, bathrooms and toilets, the kitchen and of some bedrooms and en suite toilets. All areas viewed were clean and odour well managed. The home was warm and the Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 21 lounge and conservatory well lit, adequately ventilated and comfortably furnished. The lounge, dining room and some bedrooms had been redecorated and further carpets replaced. Bedrooms on the second floor were in the process of being redecorated and there are plans to replace some items of worn furniture. Two twin rooms had been converted. All bedrooms are now for single occupancy though this has reduced total occupancy numbers to fifteen. An additional two en suite toilets had been achieved as part of the building programme. Assisted toilets and bathrooms were clean and fresh. It was recommended that the bolt on the toilet door at the top of the stairs on the first floor be replaced with a safety lock. The provider advised that currently only staff use this facility. The need to review the adequacy of storage for toiletries in the en-suite toilets viewed is advised, noting these were stored on toilet cisterns. Whilst some areas still need attention to décor, specifically doors throughout the home, the manager is aware and has an action plan demonstrating commitment to ongoing improvement. The utility room was clean and the washing machine and tumble dryer were in working order at the time of the visit. The passenger lift serves all floors. Since the last inspection a small ramp had been fitted beside the front door step. The car park and rear garden were tidy. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 22 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): Standards: 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is working hard to address gaps in the staff induction and training programme. Though there is improvement in staff recruitment and vetting procedures some shortfalls were identified. Observations indicated the safety and adequacy of staffing levels based on the current number and needs of residents. EVIDENCE: Staff were attentive to residents needs and wishes on the day of the inspection visit. Interaction between staff and residents was appropriately informal, respectful and friendly. Residents able to express opinion spoke well of all staff. Positive comments about staff were received from two relatives and two professionals in survey questionnaires and from a visitor during the inspection visit. There are four full- time and seven part- time care staff, a full time cook and part time cleaner. Whilst the ethnicity and culture of the staff team does not reflect that of the majority of residents, this was not perceived to be an issue. The home’s management and operation ensures the cultural needs of residents are well understood. Language barriers were not evident to effective communication with residents and within the team. Two new care staff had been recruited since the last inspection. The gender balance of the team reflected that of the resident group. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 23 Care staff’s roles include responsibilities for personal and social care, light cleaning and laundry duties. The cleaner works three shifts each week. The improvement in staffing arrangements found at the time of the last inspection has been sustained. The staff rotas indicated the manager and care staff’s shift patterns are planned to ensure safe practice. As far as could be ascertained the rotas sampled were an accurate reflection of staffing arrangements. Staffing levels were being monitored to ensure adequate to meet residents’ needs and safe practice. Currently one waking night staff on duty is able to meet needs on the basis that all of the residents are ambulant. There is always an on-call staff member sleeping on the premises at night. Good practice recruitment and vetting procedures were mostly followed in the recent employment of two care assistants. A shortfall was that one employee had not been asked to supply a full employment history. The manager must ensure this information is sought. The job application forms need to be amended to require this information. The declaration about health in this form must enquire about prospective employees mental as well as physical health. Other areas of discussion included the need to review employment practice to ensure compliance with legal requirements. Recently employed staff did not have letters of appointment on file and not all staff had been issued with contracts. It is strongly advised that interview records also be retained. The requirement to maintain a record of the date staff commence employment was also discussed. The new staff were verified to have had Criminal Records Bureau (CRB) Disclosures and checks made against the Protection of Vulnerable Adults (POVA) register prior to taking up post. The need to adhere to the CRB policy for storage, recording and disposal of CRB Disclosures was discussed, ensuring these are kept until the time of the next CSCI inspection after the date of issue. Both new staff had been issued with induction progress workbooks that predated the Common Induction Standards. This had been fully completed and signed off by the manager for one care assistant and was almost complete for the second. Observations confirmed the workbook did not fully cover the Common Induction Standards. The manager was advised to contact Skills to Care to clarify requirements. This does not change pre-existing requirement for statutory training in first aid, moving & handling, food hygiene and health and safety. The manager had undertaken first aid training and a number of staff and this training is ongoing. The team had recently received fire safety and safeguarding adults training from an external trainer. The manager and some staff had enrolled on a distant learning infection control training course and food hygiene training for the team was planned the week after the visit. Staff’s training files and certificates were sampled. Moving and handling updated training had not yet taken place. Four staff had achieved National Vocational Qualifications (NVQ) Level 2 in health and social care. The minimum standard for 50 of care staff trained to this level is therefore not met. Two care staff were said to have recently enrolled to undertake NVQ Level 2 training. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 24 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): Standards: 31, 33, 35, 37, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Aspects of the home’s management and administration have improved though further development necessary in other areas. Specifically fire procedures, risk assessment and care planning, staff recruitment and induction. It was positive to note the manager had attended various training events since the last key inspection and recommended he obtain a relevant management qualification. Quality assurance systems should incorporate audit activity. EVIDENCE: The manager reported that since the last key inspection he had arranged for support to be available from a care consultant, in an advisory capacity. Documentation to evidence this information was not available. Although the manager has relevant professional qualifications and experience, because he does not have a relevant management qualification, Standard 31 is not fully Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 25 met. The manager confirmed his intention to imminently enrol with a college to study for the registered managers award (RMA) qualification. He was urged to explore a course combining the RMA and NVQ Level 4 management qualifications. The Certificate of Registration is prominently displayed in the home. T he manager stated his intention to apply to the CSCI for variation of registration reducing the number of places following upgrading work. Improvement was evident in areas of the home’s management since the last key inspection, resulting in good outcomes for residents. It was positive to note self-evaluation processes had identified areas for further improvement and accordingly an action plan was actively being progressed to raise standards. This included transferring to a new care planning system and an ongoing upgrading and redecoration programme that includes new carpets and replacement of furniture. It was good to note two new care staff had been employed, which had enabled safer working practices. Areas of discussions with the manager included the need for priority to be given to finalising the draft revised fire evacuation procedure; also for staff training in this procedure. It is recognised that the team recently had fire safety training however this did not cover the revised evacuation and emergency plan. The change was identified to be necessary at the time of a fire safety audit carried out by the Surrey Fire & Rescue Service. The improvements identified were in response to a change in the law. A time specific corrective action plan was required by the Fire Service to be in place, and for the changes to be reflected in the home’s fire risk assessment. A company specialising in fire safety has carried out a fire risk assessment. Noting inaccuracies in the new risk assessment however the manager has asked a fire safety officer from this company to visit and review the risk assessment. The manager has confirmed since the visit that two doors without effective self-closing devices had received attention and these are in place. A smoke detector was identified to be necessary in the conservatory when the risk assessment was carried out. Further attention is necessary to the staff recruitment and induction procedures and related records. The manager must satisfy himself that a self-employed professional contracted by the home to provide a service to residents and has unsupervised access to them, has the requisite vetting checks. The home has a wide range of policies and procedures some of which were identified to need updating. The need to identify lines of responsibility in the home when the manager is not there was also discussed. It is essential that staff know who is in charge and that person aware of their responsibility to take any action required including dealing with emergencies. This information should be included in the staff rota. Quality assurance systems include daily direct observation of staff practice by the manager. A questionnaire survey is used annually to obtain feedback from residents who are able to complete the same. This had not been repeated Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 26 since the last key inspection. The manager had acted on some suggestions made by a resident in the last survey. Examples included provision of realityorientating information in the home and increased opportunity for this person to go out in the community with staff. Though stated that opportunity was available for other residents to access community activities, record-keeping systems did not evidence this taking place. The manager is now aware of the requirement to share the outcome of future questionnaire surveys with residents and any action plan for improvement. He said the small number of residents enables daily contact with them and regular contact with visitors. This affords opportunity for the voice of residents and relatives to be heard and influence decisions about the home. The manager has also completed and returned the Annual Quality Assurance Assessment (AQAA) to the Commission for Social Care Inspection (CSCI). This demonstrates self-evaluation systems in place, clearly identifying where the home provides a good service and areas for further development. The manager ensures safe working practices and a programme of first aid training and other staff training is ongoing. He is aware that some staff need refresher training in moving and handling. The home is secure and upstairs windows are fitted with restrictor chains for safety. Hot water temperatures are monitored and a record is maintained. Most radiators have been covered and two unguarded radiators in a bathroom and separate toilet were turned off to prevent risk of burns. The manager confirmed it was not possible to fit radiator covers in these confined areas. Both rooms were warm, being heated by corridor radiators. Call bells were available in the areas of the home inspected and noted to be working. Cleaning materials were securely stored and COSHH data records stated to exist. A risk assessment needs to be carried out for residents’ access to toiletries in their bedrooms. Residents’ moving and handling risk assessments need to be further developed, using recognised tools for this purpose. The home does not have a hoist. At time of the inspection visit all residents were ambulant. The manager advised he would hire a hoist if the use of one became necessary. The maintenance and service records sampled demonstrated the health and safety of residents and staff were overall promoted and protected. The manager was advised to clarify the period of cover for the electrical certificate with the electrician who carried out this inspection in 2004. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 27 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x 2 2 Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(1) 13(4)(c) Requirement Timescale for action 12/02/08 2. OP8 23(n) 3. OP18 13(6) 4. OP30 12(1) 18(1) The scope of residents’ risk assessments needs to be extended and care plans further developed to promote and make proper provision for their health and welfare, ensuring also that social and diversity needs are addressed. Care notes need also to demonstrate how all of these needs are being met. For the home to have equipment 12/01/08 to enable weight loss or gain to be monitored, ensuring residents’ health and welfare. For the manager to satisfy 12/12/07 himself of the vetting credentials of a self employed professional contracted by the home for provision of a service to residents, entailing unsupervised access to them in bedrooms. For staff responsible for the 12/12/07 home in the manager’s absence to be trained and competent to comply with the care plan for a resident with insulin dependent diabetes, ensuring a safe response to indicators of hypoglycaemia. DS0000013548.V352103.R01.S.doc Version 5.2 Alexander Lodge Page 29 5. OP37 17 (1) (2) 6. OP37 19 (1) 7. OP38 23(4) 8. OP38 23(4) The records specified in Schedules 3 and 4 must be maintained up to date. Specifically a current photograph of each resident and a record of all persons employed at the home, which includes the date on which they commence and cease employment. For information and documents in respect of persons employed in the home to include a full employment history, together with a satisfactory written explanation of any gaps in employment. CRB Disclosures must be stored, recorded and disposed of in accordance with CRB policy. There is a need to review areas of employment practice as detailed in the report. For the draft revised fire evacuation procedures to be finalised and all staff trained in the new evacuation procedure. For the CSCI to receive a copy of the action plan with timescales for compliance with requirements made by the Surrey Fire & Rescue Service. 12/12/07 16/11/07 03/12/07 12/12/07 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 For the care planning process to be more inclusive, care plans should be drawn up with residents’ involvement, recorded in a style that is accessible to them and agreed and signed by residents or their representative if they are unable to do so. For review of the home’s safeguarding adults procedure to DS0000013548.V352103.R01.S.doc Version 5.2 Page 30 2. OP18 Alexander Lodge 3. 4. 5. 6. OP28 OP31 OP30 OP31 7. OP33 8. 9. 10. OP37 OP38 OP38 clarify responsibilities as outlined in the report. For a minimum ratio of 50 trained members of staff (NVQ Level2 or equivalent) to be provided. For the manager to obtain relevant management qualifications. For review of the staff induction booklets to ensure the Common Induction Standards are fully covered. For the staff rota to identify staff in charge of the home in the manager’s absence. The lines of responsibility in the home must be clear to ensure staff on duty know who is responsible for taking actions and decisions including implementing emergency procedures. For quality assurance systems to be developed and incorporate regular quality audits. The outcomes of the resident surveys carried out annually should be summarised and this information supplied to residents together. For residents’ files to comprehensively include all relevant information including professional assessments and review records. For the bolt on the first floor toilet door to be replaced by a safety lock. For a smoke detector to be fitted in the conservatory. Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Alexander Lodge DS0000013548.V352103.R01.S.doc Version 5.2 Page 32 - 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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