Inspection on 28/11/06 for Alexander Lodge

This inspection was carried out on 28th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexander Lodge 12/11/08

Alexander Lodge 12/11/07

Alexander Lodge 07/06/07

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 Sandra Holland Key Unannounced Inspection 28th November 2006 10:00 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.V322975.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.V322975.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.V322975.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) 3rd August 2006 Date of last inspection 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, four of whom may have dementia and two of whom may have a physical disability. The accommodation consists of twelve single rooms, two double rooms (which may also be used as single rooms), a lounge with a conservatory, and appropriate laundry and kitchen facilities. A small garden is situated to the rear of the home, and parking for approximately four vehicles is available to the front of the property. The fees at this service range from £385.00 to £450.00 per week. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the second to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007 and was carried out under the CSCI “Inspecting for Better Lives” programme. Mrs Sandra Holland, Lead Inspector carried out the inspection over seven hours. Mr Izette Davies, Registered Provider and Registered Manager was present representing the service. For clarity, Mr Davies will be referred to throughout this report as the manager. Mrs Desline Davies, who is also a Registered Provider at the service, arrived later. A tour of the premises was undertaken and a number of documents and records were sampled, including care plans, medication administration records (MARs), staff files and health and safety records. Six residents, two staff, a visitor and a visiting healthcare professional were spoken with during the course of the inspection. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. As part of this unannounced inspection, the quality of information given to people about the care home was looked at. People who use the service were also spoken to, to see if they could understand this information and how it helped them to make choices. The information referred to included the Service User’s Guide (sometimes called a brochure or prospectus, statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out, regarding the information that people receive about care homes for older people. A report will be published in May 2007 and further information on this can be found on our website www.csci.org.uk. The inspector would like to thank the residents, staff and management for their time and assistance. What the service does well: Residents spoke of the kindness of the staff at the home. The needs of residents were assessed before they moved into the home. The healthcare needs of residents are well met. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 6 The meals served at the time of inspection were being enjoyed by residents. Most areas of the home were clean and freshly aired. A number of improvements have been made to the internal and external decoration of the home. The provider / manager is in day-to-day involvement in the home and is accessible to residents, visitors and staff. What has improved since the last inspection? What they could do better: Residents and CSCI must be supplied with a copy of the home’s and service user guide and CSCI must be supplied with a copy of the home’s statement of purpose. All areas of the home’s pre-admission assessment should be completed, including those areas that do not apply, to indicate that they have not been overlooked. Assessments of any risks to residents must be kept up to date to reflect changing needs. Record keeping in respect of medication must be improved. The receipt of all medication into the home must be recorded. The stock of medication in the Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 7 home must accurately match the record held and the record keeping must enable an audit trail to be followed. The menu plan must be reviewed, with the involvement of a dietician, to ensure it fully meets the needs of all residents. The complaints and abuse procedures must be reviewed. The paper towel dispensers which have been fitted in hallways should be fitted within the bathrooms or toilets, to prevent the spread of infection. It is recommended that an up to date copy of the Surrey Multi-Agency procedure for the Protection of Vulnerable Adults should be obtained and kept in the home. The staffing in the home must be reviewed to ensure that sufficient staff are available to meet residents needs and to ensure staff or management do not have to work excessive hours. Persons must not be employed to work at the home unless all the specified information and records have been obtained regarding those persons. The home must be managed with sufficient care, competence and skill. A system must be established and maintained to assess the quality of the service provided. Records that are required to be kept in the home must be maintained and kept up to date. A record must be maintained of all visitors to the home, including the names of visitors, a staff rota must be maintained including a record of whether the rota was actually worked and erasing fluid must not be used to make amendments to the staff rota. Notifications must be made to CSCI regarding any event that affects the welfare of residents, as required under Regulation 37. (A full explanation of this requirement is given at Standard 37). Products hazardous to health must be stored in locked cupboards, the temperature of the hot water supply must be tested regularly and a record kept and equipment in the home must be appropriately serviced to ensure it is safe to use. 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 Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Alexander Lodge DS0000013548.V322975.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.V322975.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): 1, 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident needs to be supplied with a copy of the home’s statement of purpose and service user guide, although these are made available to prospective residents and visitors. The needs of residents are assessed before they moved into the home. EVIDENCE: To enable prospective residents to make an informed choice about entering the home, it is required that they are provided with a service users guide, which is also known in some homes as a brochure or prospectus. The manager stated that the statement of purpose and the service user guide for Alexander Lodge are shown to and made available to, prospective residents or visitors, but have not been supplied to individual residents, as is required. It was agreed at the last inspection carried out in August this year, that updated copies of the statement of purpose and service user guide would be supplied to CSCI, but these are yet to be received. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 11 Each resident is supplied with a contract detailing the terms and conditions of their residence at the home. A number of residents are supported financially by a local authority and where this is the case, a copy of the local authority contract has been supplied and held in the home. For one resident, a contract has been prepared and is ready to present to the resident. The manager advised that he is waiting for the resident to be supported by a friend or relative, to ensure that the resident is aware of what is required and what is to be signed. The manager stated that if the level of the residents’ fees are to be changed, this is discussed with the resident and, or their representatives. Although letters are not sent to residents or their representatives, the manager was able to provide a record of the discussions held and the agreed outcome. For residents who receive financial support from local authorities, the manager advised that fee changes are governed by the individual local authorities and have to be accepted. The files of a number of residents were seen including that of a recently admitted resident. The manager stated that the needs of the recently admitted resident had been assessed before the admission took place, although the pre-admission assessment form had not been dated. The assessment was comprehensive although a small number of areas, including any allergies, had not been completed. It is recommended that all areas are completed or marked, including any areas which are not applicable, to indicate that they have been considered and not overlooked. The manager advised that some residents are financially supported by a local authority, and that where this is the case, an assessment has also been carried out under the care management process. A letter was seen advising that a recent care management assessment would be forwarded to the home. The manager stated that intermediate care is not provided at the home. A requirement has been made regarding Standard 1 and a recommendation has been made regarding Standard 3. Alexander Lodge DS0000013548.V322975.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): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care are available to guide staff to meeting the needs of residents, but risk assessments need to be more detailed and regularly reviewed. The management of medication in the home needs to be more robust to ensure residents receive their medication as prescribed and to ensure they are safeguarded. EVIDENCE: The manager stated that a plan of care has been drawn up for each resident, using the information gathered from the pre-admission assessment as a base. The plans are used to guide staff to the care and support needs of residents and include daily notes to record how these needs have been met. The care plans were seen to include assessments of risks to residents including the risks associated with mobility, falling, self-neglect and moving and handling. The assessments were not detailed and did not advise staff of control measures which could be used to minimise the risks and for one resident, the risk assessment had not been updated to reflect changes in Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 13 needs. The initial risk assessment carried out at the time of the resident’s admission, had no risks recorded. This resident had fallen and sustained an injury requiring hospital treatment, but the risk assessment had not been updated to reflect this. It was clear from the records seen, that the healthcare needs of residents are appropriately met. Entries in residents’ care plans recorded the involvement of a number of healthcare professionals, including general practitioners (GP’s), community nurses, a psychiatrist and a chiropodist. A visiting healthcare professional was spoken with and it was pleasing to hear that appropriate and timely referrals are made when a change is noted in a resident’s health. It was also advised that staff at the home are receptive to any recommendations which are made and staff ensure that any treatment needs are met. The administration of medication needs to be managed more effectively and robustly to ensure that residents are safeguarded and they receive their medication as prescribed. The manager stated that medication is supplied to the home by a local pharmacy. When the amounts of medications in the home were checked with the records held, it was of concern that these did not accurately match. The quantities of four individual medications were checked and none of these accurately matched the record. The receipt of another medication had not been recorded, although some of the medication had been used. The manager stated this medication was no longer required and was to be returned to the pharmacy. As the receipt had not been recorded, it was not possible to know when it had been administered or to follow an audit trail. A further medication had been received in the home and the details had been handwritten onto the medication administration record (MAR) chart. It was noted that only the name and the strength of the medication had been entered onto the MAR chart, but the dose, the frequency or the timing of the medication was not stated. An immediate requirement was made at the previous inspection carried out on 3rd August 2006 regarding the recording of the receipt of medication, that the amounts held must accurately match the record held and that the records must be such that it is possible to follow an audit trail. This has not been met. Staff were observed to speak to residents in a friendly and informal but appropriate manner. Assistance with personal care was given in a way that respected residents’ privacy. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 14 An immediate requirement has been made regarding Standard 9 and the timescale for the requirement regarding Standard 7 has been given an extended timescale. Alexander Lodge DS0000013548.V322975.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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities are carried out, but these have not been varied for a number of years. The menu plan needs to be reviewed to ensure it meets the specific nutritional needs of some of the residents. EVIDENCE: It was disappointing to observe that no activities were taking place on the day of inspection. The manager advised that due to the absence of a member of staff, he was taking the role of the second member of staff on duty. A further member of staff arrived later to enable the manager to assist with the inspection process. A requirement was made at the last inspection carried out in August 2006, that the activities programme must be reviewed in consultation with residents, appropriate facilities must be provided for residents’ recreation and these must take residents’ needs into account. The manager stated that he has consulted with residents, who advised that they are happy with the activities currently on offer, but the manager stated that he could not demonstrate this. It is recommended that residents’ views regarding their choice of activities is Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 16 gathered and recorded in their individual plans. Residents’ views on activities should also be included in the planned quality survey. During the course of the inspection, one resident was reading her newspaper, whilst music was playing in the lounge and the television was on later in the day. A number of residents were sleeping in their chairs in the lounge and appeared to lack stimulation. One resident has brought hobby equipment into the home, and the manager advised that staff are assessing the resident to see what support is needed. It was clear that visitors are made welcome at the home and a visitor on the day of inspection was spoken with. The visitor advised that he was from a local church and was visiting a resident who had not been able to attend the church in person recently. Residents spoke of bringing their own possessions with them when they moved into the home, to personalise their rooms. One resident happily showed me her room which contained a number of her own belongings and which she was very content with. A number of other resident bedrooms were seen to have their own small items of furniture, pictures, photographs and ornaments. Residents were spoken to during the lunchtime meal that was served, and which residents said they had enjoyed. The meal looked appetising and well balanced. During the tour of the kitchen, it was noted once again, that a portion of porridge was stored in the fridge, which the cook stated was to be served to a resident for their evening meal, as they require a soft diet. As information previously supplied states that special diets can be provided for, it is required that the menu plan on offer is reviewed. This is to ensure the meals offered are suited to the needs of all residents and are appropriate to the time of the day. Where residents require their food in an alternative form, such as pureed, it is recommended that wherever possible, the meal is similar to the meal other residents are being served. It is required that a referral is made to a dietician to ensure that residents requiring a special or adapted diet are being adequately nourished. A recommendation has been made regarding Standard 12 and a requirement has been made regarding Standard 15. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, but the review and revision of this needs to be completed. Staff have received training in the safeguarding of vulnerable adults. An updated version of the local authority procedure needs to be obtained. EVIDENCE: The home’s complaints procedure was available on the table in the entrance hall at the last inspection and was seen to be very brief, with only a small section referring to addressing any complaint or concern within the home. A section in larger print advised contacting CSCI or the Ombudsman. The procedure stated that a response to any complaint would be made in writing within seven days of a complaint being made. It was required following that inspection, that the complaints procedure is reviewed and revised, even though the procedure was marked as “reviewed June 2006”. It required greater emphasis on the resolution of any complaint or concern within the home, as this is the responsibility of the manager. The name, address and telephone number of CSCI was to be included. The manager stated that he is in the process of reviewing the complaints procedure, but this has not been completed. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 18 A summary of the home’s complaints procedure is attached to the contract supplied to each resident on admission, although as previously noted, one resident has yet to receive a contract. Residents who were spoken to, advised that they would speak to the manager or a member of staff if they had a complaint or were unhappy. Staff in the home have received training in the protection of vulnerable adults (now referred to as safeguarding adults) and staff spoken to stated that they would report any concerns to the manager or person in charge. Staff were aware that concerns could also be raised outside the home if required. The manager stated that the home would follow the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults in the event of an incident or an allegation of abuse. A copy of this procedure is held in the home for staff to refer to. It was noted at the last inspection that the copy held was an outdated copy and the manager was advised to obtain the up-dated February 2005 version. The manager stated that the updated copy was still to be obtained. The home’s policy and procedure on abuse was seen and this also requires review and revision, as it refers to an alleged abuser as “the offender”, refers to the Inspection and Registration Unit, which was disbanded four years ago and needs to refer to the Surrey Multi-Agency Procedure. The requirement previously made regarding Standards 16 and the recommendation regarding Standard 18 have been given extended timescales. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Areas of the home have been improved, but further maintenance and attention to the premises is required. Efforts have been made to improve hygiene in the home. EVIDENCE: A full tour of the premises was carried out and it was clear that work had been carried out in a number of areas to improve the facilities available, although on-going attention to detail and further maintenance of the premises is required. Bathroom and toilet floors had been renewed and a number of bedrooms had been decorated and carpeted. The manager stated that it is planned to create an office area in the entrance hall of the home, and a new desk had been fitted for this purpose. Although the items noted here do not represent a risk to residents, they have an impact on the quality of residents’ daily lives. A number of resident’s Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 20 bedroom door handles are still to be repaired or replaced as they hang in a downward position, and one does not close properly. Tiling and the sealant around the bath in an upstairs bathroom still need attention to make it a pleasant place in which to bathe. A small number of vanity units in bedrooms require attention, as one had a loose door, one was very worn around the edges and two showed signs of previous leaks. A requirement was made following the last inspection that the home must be kept in good state of repair and all parts of the home must be kept clean and reasonably decorated. This requirement has been partially met and the timescale will be extended to enable it to be fully met. Although odour control was generally effective, two resident rooms require attention to ensure they are odour free and are pleasant for the resident or their visitors to use. Efforts have been made to improve hygiene in the home. It was observed that liquid soap had been provided in some but not all, bathrooms and toilets. Paper towel dispensers had been provided, but had been fitted outside bathrooms, in the communal hallway. It was strongly recommended that the paper towel dispensers were fitted within the bathrooms and toilets to reduce the risk of the spread of infection. The timescale for the requirement regarding Standard 19 has been extended and a recommendation has been made regarding Standard 26. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported and cared for by a very small team of staff who have received appropriate training. Recruitment must be carried out more thoroughly to safeguard residents. EVIDENCE: From the information contained in the staff rota it was clear that residents are supported by a very small team of staff, some of whom have been employed at the home for two years or more. The majority of staff are carers and they carry out housekeeping and laundry tasks in addition to care and activities. A cook is employed to work at the home for five or six days each week on average. The manager is also listed on the staff rota to work six days each week, and as previously noted, the manager was taking the role of the second member of staff on duty, on the day of inspection. It was noted that three staff had left the home prior to the last inspection, two of these staff worked full-time and one worked part-time. The manager stated that one new member of staff had been recruited to replace them, but it was evident at the time of inspection that further staff need to be recruited. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 22 It was required following the last inspection that staffing in the home must be reviewed to ensure that there are sufficient staff working at the home at all times to meet the needs of residents, whilst safeguarding staff or management from working excessive hours. Although this requirement has not been met, the timescale has been extended to enable compliance. A number of staff have achieved a National Vocational Qualification (NVQ) to Level 2 in care and the home meets the recommended target of fifty percent of staff with this qualification. From the records seen, it was clear that the standard of recruitment processes in the home must be more robust and thorough to ensure that residents are safeguarded. From the records seen, it was noted that a recently recruited member of staff had not fully completed their application form, and essential information had not been recorded. The application form had not been signed or dated by the applicant. For this member of staff, no record of their induction was available, as the manager stated that it was held elsewhere. It is required that induction records are maintained and retained in the home, to be available for inspection. Staff have undertaken training required by law, including fire safety, food hygiene and first aid, and other training to develop their knowledge and skills including NVQ’s and prevention of abuse. The staff team is culturally and racially diverse, although this is not reflected in the resident group. An immediate requirement was made regarding Standard 29 and a requirement regarding Standard 30 has been made. The timescale for the requirement regarding Standard 27 has been extended. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home needs to be more robust and effective to ensure that the required standards are met, and to ensure the safety of residents. EVIDENCE: The management of the care home needs to be more robust, and effective monitoring needs to be carried out to ensure that residents are safeguarded and a quality service is provided to residents. More thorough recruitment procedures, planned and regular maintenance of the home and a review of the staffing levels are required. It is of serious concern that the four immediate requirements made at the last inspection have not been met. Written details of the shortfalls were left at the home at the time of the inspection and were followed by a letter of serious Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 24 concern. The manager supplied written confirmation that the immediate requirements made at the inspection had been complied with, but this was not evident at this inspection. A requirement was made following the last inspection that the manager must manage and carry on the home with sufficient care, competence and skill. He must also undertake from time to time such training as is appropriate to ensure he has the experience and skills necessary for managing the care home. The manager stated that he has undertaken statutory training courses within the last two years, but did not have the certificates available at the home. He also stated that he has not undertaken a management qualification as recommended by the National Minimum Standards for Older People. At the last inspection the manager stated that a resident survey is carried out annually, the most recent being dated 2004/2005, and that it was intended to repeat this in the near future. A requirement was made following that inspection that a review of the quality of the service must be carried out and a summary of the responses received must be made available to residents and a copy forwarded to CSCI. The manager stated that this had not yet been carried out. Residents’ monies are not held for safekeeping the manager advised. Any additional expenses on residents’ behalf is paid for by the home and invoiced to the resident or their representative. An immediate requirement was made at the last inspection carried out in August this year, that the required records must be maintained in the home, including an accurately maintained staff rota and record of visitors. This requirement has not been met, as amendments had been made to the rota using erasing fluid and the record of visitors had not been maintained. The inspector was not asked to sign the record on her arrival and it was observed that no entries had been made in the visitors’ book for ten days prior to the inspector’s entry. The manager confirmed that a number of visitors had been to the home during that period. It was also of concern that notifications had not been made to CSCI under the requirements of Regulation 37. This regulation requires homes to notify CSCI of events that occur in the home and affect the welfare of residents, including serious illness, serious accident, death and theft. The manager stated that a resident had been admitted to hospital and subsequently died there, but these events had not been notified to CSCI. An immediate requirement was also made at the last inspection regarding three hazards to the health and safety of those in the home. This has been partially met, as fire doors were not wedged open and restrictors had been fitted to windows to prevent them opening fully, and to safeguard against anyone falling from them. The requirement that products hazardous to health Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 25 must be stored in a locked provision had not been met, as these products were again stored in an unlocked cupboard in the kitchen. A number of records relating to health and safety were sampled, including gas safety, fire safety and food temperature records and these indicated that they have been carried out to the required frequency. It was noted however, that the bath hoist had not been serviced for over a year and the manager stated that regular tests of the temperature of the hot water supply have not been carried out as required. Two immediate requirements have been made regarding Standards 37 and 38 and the requirements regarding Standards 31 and 33 have been given extended timescales. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X 1 1 Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 OP2 Regulation 4&5 Requirement Timescale for action 23/02/07 2 OP7 13(4) (c) 3 OP9 13 (2) 4 OP15 16 (2) (i) A copy of the home’s service user guide must be supplied to each resident and a copy supplied to CSCI. A copy of the home’s statement of purpose must be supplied to CSCI. Assessments of risks to residents 02/02/07 must be regularly reviewed and amended to reflect residents’ changing needs. Arrangements must be made for 28/11/06 the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Specifically, a) the receipt of all medication received in to the home must be recorded, (b) all medication administered must be recorded, (c) the amounts of medication held in the home must accurately match the record held and (d) the records must be such that it is possible to follow an audit trail. The menu plan must be reviewed 02/03/07 to ensure it meets the needs of residents. For those residents with specific dietary needs, the DS0000013548.V322975.R01.S.doc Version 5.2 Alexander Lodge Page 28 5 OP16 22 6 OP19 23 (2) (b & d) 7 OP26 13 (3) 8 OP27 18(1) (a) 9 OP29 19 10 11 OP30 OP31 17 & 18 10 12 OP33 24 involvement of a dietician must be sought to ensure residents are adequately nourished. The home’s complaints procedure must be reviewed to reflect actions to be taken in the home and the timescales for a response. The complaints procedure must be suited to the needs of residents. The premises must be maintained in a good state of repair and all parts of the home must be kept clean and reasonably decorated. Arrangements must be made to prevent infection, toxic conditions and the spread of infection at the care home. Specifically, liquid soap and paper towels must be provided and used in the home. Staffing at the home must be reviewed to ensure that sufficient staff are working at the care home to meet the needs of residents. A person must not be employed to work at the care home unless they are fit to work there and the required information and documents have been obtained in respect of that person. A record of staff induction must be maintained and retained in the care home. The registered provider / manager must manage and carry on the care home with sufficient care, competence and skill. He must also undertake from time to time such training as is appropriate to ensure he has the experience and skills necessary for managing the care home. A review of the quality of the service provided must be carried out and a summary of the DS0000013548.V322975.R01.S.doc 02/03/07 02/03/07 05/01/07 23/02/07 28/11/06 28/11/06 02/03/07 02/03/07 Alexander Lodge Version 5.2 Page 29 13 OP37 17 14 OP38 13 (4) (a) responses received must be forwarded to CSCI and made available to residents. The records specified in Schedule 28/11/06 4 must be maintained in the home and must be kept up to date. Specifically, a) the staff rota must record the staff working in the home and the hours actually worked; b) a record must be kept of all visitors to the home including the names of visitors and c) notifications must be made to CSCI as required by Regulation 37. All parts of the home to which 28/11/06 residents have access must be free from hazards to their safety. Products hazardous to health must be stored in a locked provision; the temperature of the hot water supply must be tested and a record maintained and equipment used in the home must be appropriately serviced to ensure it is safe to use. 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 OP3 Good Practice Recommendations It is good practice to complete all areas of the preadmission assessment. Areas that do not apply should be marked accordingly, to confirm that these have been not overlooked. It is recommended that each resident’s choice of social and recreational preferences are recorded. It is recommended that an up to date copy (Feb 2005) of the Surrey Multi-Agency procedure for the Protection of Vulnerable Adults is obtained and kept in the home. It is DS0000013548.V322975.R01.S.doc Version 5.2 Page 30 2 3 OP12 OP18 Alexander Lodge 4 OP26 also recommended that the home’s policy on abuse is reviewed to reflect the Surrey Multi-Agency procedure and to incorporate more appropriate wording. It is recommended that the paper towel holders fitted in the hallways are fitted within the bathrooms and toilets, to reduce the risk of the spread of infection. Alexander Lodge DS0000013548.V322975.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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